PLACE LABEL HERE

ALCOHOL WITHDRAWAL

EMERGENCY DEPARTMENT

ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

1.Initiate this order set if patient’s CIWA score greater than8

2. Diet:  Regular  Consistent Carb diet Low Sodium/Cardiac NPO

3. Mental Health Consult (once patient is medically cleared)

4. Suicide Precautions

5. Laboratory:CBC, CMP, Magnesium, PT/INR, UA, Urine and Blood Drug Screen (if not ordered):

Repeat blood alcohol level q 4 hrs after initial blood alcohol level until < 200 mg/dL

6. Vital signs q 4 hrs and prn, notify physician if temp ≥101°F

7. Activity (advance as tolerated):

Bedrest Bedside Commode Bathroom privileges Up ad lib Up with assistance

MEDICATIONS:

8. IVF (no additives): NS at ______ml/hr or LR at ______ml/hr

9. Thiamine 500 mg IVPB over 30 minutes q8hrs x 3 days, then 100 mg IV orpo daily.

10. Folic Acid 1 mg IVPB daily x 3 days.

11. Multivitamin (MVI) 1 tablet po daily.

PRN Medications:

12. Magnesium Replacement for Magnesium less than 1.8:

Magnesium sulfate 2 gm IVPB over 1 hour for Mg level 1.5-1.7

Magensium sulfate 4 gm IVPB over 2 hour for Mg level < 1.5

13. Nausea/Vomiting:

Zofran (ondansetron) 4 mg IV or po q 6 hrs prn

If N/V persists, addReglan (metoclopramide) 10 mg IV or po q 6 hrs prn (5 mg if > 65 y/o)

14. CIWA-Ar score

Copy to pharmacy Order writer’s initials ______

*3-33651* FORM 3-33651 REV. 08/2017 Page 1 of 3

PLACE LABEL HERE

ALCOHOL WITHDRAWAL

EMERGENCY DEPARTMENT

ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

Select either Prevention Dosing or Symptom Triggered Dosing Not both

15. For CIWA scores ≥ 8 Notify Physicianto change dosing to Symptom Trigger Dosing

16. Prevention Dosing(Prevention dosing is for the patient with known history of Alcohol WithdrawalSyndrome or Delirium Tremens (DT) in the past)

Complete Clinical Institute Withdrawal Assessment (CIWA-Ar) form # 17361, q 4 hrs

Choose one of the below meds for prevention dosing: Chlordiazepoxide (Librium) or Lorazepam (Ativan)

Chlordiazepoxide dose (oral) is the preferred for patients with Renal Failure

50 mg po q6 hrs x 4 doses, then

25 mg po q6hrs x 8 doses, then discontinue

Lorazepam dose (oral orifnpo give IV) is preferred for elderly patients and those with liver disease

2 mg po q4 hrs x 12 doses, then

1 mg po q4 hrs x 6 doses, then

0.5 mg po q4 hrs x 6 doses then discontinue

Select either Prevention Dosing or Symptom Triggered Dosing Not both

17. Symptom Triggered Dosing (Symptom triggered dosing is for patients with active or suspected withdrawal). Medication PRN only basis depending on symptoms. Check desired medication below.

CIWA-Ar score / Chlordiazepoxide (oral)a
Preferred for patients with Renal Failure / Lorazepam
(oral or IV)
Preferred for elderly patients and those with liver disease
1-7 CIWA Score
Assess VS/ unit routine
Assess CIWA q4 hrs / No SymptomTriggered medication needed.
Continue CIWA q4 hrs for 3 checks, if remains <8, then reassess q 8 hrs.
8-10 CIWA score
VS and CIWA q 2 hrs / Chlordiazepoxide
25 mg po q 2 hrs prn / Lorazepam
1 mg (PO or IV) q 2 hrs prn
CIWA-Ar score of 10 or higher indicates the need for higher doses
11-15
VS and CIWA q 1-2 hrs / Chlordiazepoxide
50 mg po q 1 hr prn
If unable to administer po switch to IV Lorazepam dosing / Lorazepam
2 mg (PO or IV) q 1 hr prn
16-19
VS and CIWA q 1 hrs / Chlordiazepoxide
100 mg po q 1 hr prn
If unable to administer po switch to IV Lorazepam dosing / Lorazepam
4 mg (PO or IV) q 1 hr prn
≥ 20
VS and CIWA q 1 hrs / Notifiy provider to assess patient

Copy to pharmacyOrder writer’s initials ______

FORM 3-33651 REV. 08/2017 Page 1 of 3

PLACE LABEL HERE

ALCOHOL WITHDRAWAL

EMERGENCY DEPARTMENT

ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

18. Symptoms for multisubstance abuse disordermay require adding Opioid Withdrawal Orders

(form # 43095).

ADDITIONAL ORDERS:

______

______

______

______

______

______

FOLLOW-UP CARE: Admission: Use Alcohol Withdrawal Orders (form #39661)

 Transfer to Mental Health Facility if medically stable

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-33651 REV. 08/2017 Page 3 of 3