Order Set (Print Single Sided)

PMH, TGH, TWH

Emergency Department Alcohol
Withdrawal
Personal Health Information (PHI) label

Approval for Use: Emergency Department

Prescriber to check all appropriate boxes (  ). To exclude pre-checked (  ) orders, strikeout and initial the orders.

1. MONITORING:
 Vital signs (temp, HR, RR, BP, SpO2) q1h and as needed

Notify Physician immediately if SBP less than 90 mmHg or RR less than 12

bpm, HOLD diazepam
Patient Assessment
 Document the patient assessment using the UHN Clinical Institute Withdrawal
Assessment – Alcohol revised (CIWA-Ar) Score Record (Form D-6638).
 Assess patient and calculate CIWA-Ar Score q1h (wake patient if asleep)
 Discontinue CIWA-Ar scoring when two consecutive scores are less than 10
AND notify physician

2. LABORATORY TESTS:
 CBC, Glucose, Sodium, Potassium, Chloride, Creatinine, Bicarbonate, Calcium,
Magnesium, Phosphate now
ALT, AST, Total Bilirubin now
 Lipase now
 Plasma Ethanol Level now
 Other: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3. IV THERAPY:
If CIWA-Ar greater than 10
 Initiate IV
 0.9% sodium chloride IV 1,000 mL bolus over 30 minutes
THEN
 0.9% sodium chloride IV at 200 mL/hr
 Stop IV fluids when patient drinking well

4. MEDICATIONS:
 thiamine 500 mg IV-int in 100mL 0.9% NS or D5W for one dose
OR
thiamine 250 mg IM for one dose
Note: due to the risk profile of the ED population and the lack of follow up, the
500 mg dose is preferred if an IV is inserted

Form D-7031 (23/03/2021) _______________ Page 1 of 3

Prescriber’s Initials
Order Set (Print Single Sided)
PMH, TGH, TWH
Emergency Department Alcohol
Withdrawal
Personal Health Information (PHI) label

BENZODIAZEPINES
***max diazepam 200 mg in 12 hours***
Choose one of the following regimens and the appropriate route(s) of
administration:
A) Standard Dosing
CIWA-Ar greater than 10:
 diazepam 20 mg PO/IV push q1h

B) For patients at risk of respiratory depression, CNS depression, chronic

opiate use, or age more than 60 years:
CIWA-Ar greater than 10:
 diazepam 10 mg PO/IV push q1h
Note: prescriber may consider doubling diazepam dose after 3 doses if CIWA-
Ar is not decreasing

REFRACTORY ALCOHOL WITHDRAWAL:

If CIWA-Ar greater than 10, despite diazepam 200 mg in 12 hours:
 Move to monitored bed
 phenobarbital 60 mg in 10 mL 0.9% normal saline slow IV push over 3 minutes
by prescriber q15min as needed for symptoms of alcohol withdrawal
Note: ICU consultation required if refractory alcohol withdrawal is present.
Prescriber may consider doubling subsequent phenobarbital doses if CIWA-Ar
is not decreasing (maximum single dose is 240 mg, maximum infusion rate is
25 mg/min)
NICOTINE REPLACEMENT THERAPY
Nicotine gum 2 mg, chewed q 1-2 hours as needed
AND choose one of the following:
 If the patient typically smokes more than 20 cigarettes per day:
Nicotine patch 21 mg/day transdermal patch, change daily
 If the patient typically smokes 10 to 20 cigarettes per day:
Nicotine patch 14 mg/day transdermal patch, change daily
 If the patient smokes fewer than 10 cigarettes per day:
Nicotine patch 7 mg/day transdermal patch, change daily

Form D-7031 (23/03/2021) _______________ Page 2 of 3

Prescriber’s Initials
Order Set (Print Single Sided)
PMH, TGH, TWH
Emergency Department Alcohol
Withdrawal
Personal Health Information (PHI) label

5. DISCHARGE
 Discontinue alcohol withdrawal protocol when two consecutive CIWA-Ar scores
are less than 10
 Fax referral to Rapid Access Addiction Medicine (RAAM) clinic
 Provide patient with RAAM handout and instruct patient to visit RAAM clinic
Note: Consider outpatient pharmacotherapy for alcohol use disorder. Examples
of evidence-based pharmacotherapy (if no contraindications) include:
naltrexone 50 mg PO daily (LUC 532)
gabapentin 300 mg PO TID
Additional Orders: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__________________________________________
__________________________________________

Print Name and Designation Prescriber’s Signature Date (dd/mm/yy) Time

Phone/ Pager: _ _ _ _ _ _ _ _ _

Form D-7031 (23/03/2021) _______________ Page 3 of 3

Prescriber’s Initials