PcTx IV Final Exam
What is the pathophysiology of Alcohol Withdrawal Syndrome? - ANS--alcohol is a CNS
depressant; potentiation of GABA receptors; enhances central inhibitor tone
-chronic alcohol use leads to down regulation of GABA and up regulation of NMDA
-results in autonomic instability, behavioral agitation, and psychosis
How long does it take to develop initial withdrawal symptoms? - ANS-6-8 hours since
last alcoholic drink
What are the signs and symptoms of initial withdrawal? - ANS--tachycardia
-HTN
-increased body temp
-tremulousness
-anxiety
-N/V
-headache
-diaphoresis
-palpitations
How long does it take to develop alcohol hallucinations? - ANS-12-24 hours since last
alcoholic drink
What are the signs and symptoms of alcohol hallucinations? - ANS--tactile
hallucinations common, visual less likely
-auditory hallucinations possible (sometimes persecutory)
-tremors and other withdrawal sx
-normal sensorium
How long does it take to develop withdrawal seizures? - ANS-12-48 hours since last
alcoholic drink
What are the signs and symptoms of withdrawal seizures? - ANS--generalized
tonic-clonic (often isolated, short in duration, short post-ictal period)
What are the risk factors for delirium tremens (DT)? - ANS--history of DT
-recent withdrawal seizure (specifically if left untreated)
-CIWA-Ar ≥ 15
-hx of sustained drinking
,-pts with SBP > 150 mmHg, or pts with HR > 100 beats/min
-last alcohol intake >2 days
-age > 30
-recent misuse of other depressants such as BZDs
-concurrent medical illness such as pneumonia or active ischemia
How long does it take for one to develop DT and how long can it last? - ANS-Begins 3
days after the appearance of withdrawal symptoms and lasts 1-8 days
what are some rare, serious complications associated with disorientation and profound
autonomic symptoms? - ANS--tachycardia
-severe agitation
-fever
-HTN
What is the classification levels of the CIWA-Ar? - ANS-0-9: very mild withdrawal
10-15: mild withdrawal
16-20: modest withdrawal
21-67: severe withdrawal
What is the CIWA symptom-triggered regimen? - ANS-BZD given only when sx
necessitate, based on AWS assessment scale's score
What are the outcomes of the symptom-triggered regimen? - ANS--reduce total amount
of BSD needed
-shortens duration of treatment
-reduces need for mechanical ventilation
-reduces ICU and hospital length of stay
What is the CIWA fixed schedule? - ANS-BZD given at specific intervals and additional
doses given as needed based on the severity of the withdrawal sx
What is the goal RASS for AWS? - ANS-0-(-2)
When would you initiate a BZD tx according to the RASS? - ANS-RASS of +1
What is first line treatment for AWS? - ANS-BZDs
What are some adjunctive agents used for AWS? - ANS--phenobarbital
-propofol
, -dexmedetomidine
-ketamine
-valproic acid
-enteral ethanol
What is the MOA of BZDs? - ANS-acts as central GABAa agonists, increasing
frequency of GABA-receptor channel opening
What should you consider when giving pts ≥65 BZDs? - ANS--geriatric pts are more
sensitive to BZD doses, use lower initial doses
What are adverse effects of BZDs? - ANS--CNS and respiratory depression
-delirium
Which 2 BZDs have the longer half-lifes for AWS? - ANS--Diazepam (43+/-13)
-Lorazepam (14+/-5)
What 3 BZDs have active metabolites? - ANS--diazepam
-midazolam
-chlordiazepoxide
What is the MOA of IV Phenobarbital (PB)? - ANS--barbiturate that prolongs GABA
channel opening, which increases chloride ion influx and hyper polarizes neuronal
membranes
-inhibits glutamate receptor activity
When would you use PB for AWS? - ANS--severe BZD-resistant AWS and/or DTs
-initial dose prior to BZD therapy
-no support for monotherapy
What is the onset of action, duration, and half-life of PB? - ANS--onset of action: ~5
minutes
-duration: > 6hrs
-half-life: 53-118 hrs
What are the adverse effects of PB? - ANS--hypotension
-oversedation
-respiratory depression
-patients may require intubation
What is the pathophysiology of Alcohol Withdrawal Syndrome? - ANS--alcohol is a CNS
depressant; potentiation of GABA receptors; enhances central inhibitor tone
-chronic alcohol use leads to down regulation of GABA and up regulation of NMDA
-results in autonomic instability, behavioral agitation, and psychosis
How long does it take to develop initial withdrawal symptoms? - ANS-6-8 hours since
last alcoholic drink
What are the signs and symptoms of initial withdrawal? - ANS--tachycardia
-HTN
-increased body temp
-tremulousness
-anxiety
-N/V
-headache
-diaphoresis
-palpitations
How long does it take to develop alcohol hallucinations? - ANS-12-24 hours since last
alcoholic drink
What are the signs and symptoms of alcohol hallucinations? - ANS--tactile
hallucinations common, visual less likely
-auditory hallucinations possible (sometimes persecutory)
-tremors and other withdrawal sx
-normal sensorium
How long does it take to develop withdrawal seizures? - ANS-12-48 hours since last
alcoholic drink
What are the signs and symptoms of withdrawal seizures? - ANS--generalized
tonic-clonic (often isolated, short in duration, short post-ictal period)
What are the risk factors for delirium tremens (DT)? - ANS--history of DT
-recent withdrawal seizure (specifically if left untreated)
-CIWA-Ar ≥ 15
-hx of sustained drinking
,-pts with SBP > 150 mmHg, or pts with HR > 100 beats/min
-last alcohol intake >2 days
-age > 30
-recent misuse of other depressants such as BZDs
-concurrent medical illness such as pneumonia or active ischemia
How long does it take for one to develop DT and how long can it last? - ANS-Begins 3
days after the appearance of withdrawal symptoms and lasts 1-8 days
what are some rare, serious complications associated with disorientation and profound
autonomic symptoms? - ANS--tachycardia
-severe agitation
-fever
-HTN
What is the classification levels of the CIWA-Ar? - ANS-0-9: very mild withdrawal
10-15: mild withdrawal
16-20: modest withdrawal
21-67: severe withdrawal
What is the CIWA symptom-triggered regimen? - ANS-BZD given only when sx
necessitate, based on AWS assessment scale's score
What are the outcomes of the symptom-triggered regimen? - ANS--reduce total amount
of BSD needed
-shortens duration of treatment
-reduces need for mechanical ventilation
-reduces ICU and hospital length of stay
What is the CIWA fixed schedule? - ANS-BZD given at specific intervals and additional
doses given as needed based on the severity of the withdrawal sx
What is the goal RASS for AWS? - ANS-0-(-2)
When would you initiate a BZD tx according to the RASS? - ANS-RASS of +1
What is first line treatment for AWS? - ANS-BZDs
What are some adjunctive agents used for AWS? - ANS--phenobarbital
-propofol
, -dexmedetomidine
-ketamine
-valproic acid
-enteral ethanol
What is the MOA of BZDs? - ANS-acts as central GABAa agonists, increasing
frequency of GABA-receptor channel opening
What should you consider when giving pts ≥65 BZDs? - ANS--geriatric pts are more
sensitive to BZD doses, use lower initial doses
What are adverse effects of BZDs? - ANS--CNS and respiratory depression
-delirium
Which 2 BZDs have the longer half-lifes for AWS? - ANS--Diazepam (43+/-13)
-Lorazepam (14+/-5)
What 3 BZDs have active metabolites? - ANS--diazepam
-midazolam
-chlordiazepoxide
What is the MOA of IV Phenobarbital (PB)? - ANS--barbiturate that prolongs GABA
channel opening, which increases chloride ion influx and hyper polarizes neuronal
membranes
-inhibits glutamate receptor activity
When would you use PB for AWS? - ANS--severe BZD-resistant AWS and/or DTs
-initial dose prior to BZD therapy
-no support for monotherapy
What is the onset of action, duration, and half-life of PB? - ANS--onset of action: ~5
minutes
-duration: > 6hrs
-half-life: 53-118 hrs
What are the adverse effects of PB? - ANS--hypotension
-oversedation
-respiratory depression
-patients may require intubation
