Psychiatry
Disclaimer: the clinical information on this site is only meant to serve as a reference. Please consult with your team for individual diagnostic and treatment decisions.
Alcohol/Benzodiazepine Withdrawal
- Symptoms worse 24-72 hours after last use
- Patients with heavy alcohol use should also get thiamine (IV or IM at the beginning if giving dextrose containing fluids but do not give any dextrose until thiamine has been given via banana bag or separately), folate, and a multivitamin
- Question to ask: if history of seizures/delirium tremens (DTs) then consider prophylactic Ativan (lorazepam) with 1-2mg PO Ativan every 6 hours on day 1 x 4 doses, 1mg PO every 6 hours on day 2-3 x 8 doses
- Nurses will check CIWA score (Clinical Institute Withdrawal Assessment) with maximum score 67 made of 10 components: nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory hallucinations, visual hallucinations, headache, disorientation/clouded sensorium
- Use of Serax (oxazepam) and Librium (chlordiazepoxide) prophylaxis varies between providers and institutions
- If CIWA 0-8 can check CIWA score every 6 hours at the start, hold off on Ativan
- If CIWA 9-15 give Ativan 1mg, 2mg, or 4mg IV (sequential escalation) every 2-4 hours (monitoring vital signs and mental status within 15 minutes)
- If CIWA 16+ give Ativan 1, 2, or 4mg IV every 15 minutes until CIWA <15 then use that dose PRN every time CIWA > 15 (monitoring vital signs and mental status within 15 minutes of dose)
- Consider transfer to ICU if unable to protect airway, CIWA > 15 for more than an hour, given Ativan > 6mg in 1hr or > 12mg in 6hrs, hemodynamic instability
- If relatively low use of Ativan PRN can just stop and monitor
- If relatively high use of Ativan PRN but then CIWA 0-8 for over 24 hours, can calculate total use of Ativan in 24 hours and give over 4 divided q6hr doses and taper by 20% per day afterward
- Rapid response differential: stroke (ischemic or hemorrhagic), sepsis, hypoglycemia, cardiac arrhythmia (check pulse), seizure, medication side effect, hypercarbia, delirium
- Rapid response diagnostics: consider finger stick, head CT/MRI, infectious workup, telemetry, medication list review, Ativan (lorazepam) and Keppra (levetiracetam) IV load, or ABG
- Other differential diagnoses: dialysis disequilibrium syndrome, alcohol or drug withdrawal, carbon monoxide poisoning, hypoxia, hypo or hypernatremia, alkalemia, hypercalcemia, sundowning
- Considering using the GAD-7 score to diagnose generalized anxiety disorder
- If while in the hospital and need a fast-acting agent (try to avoid given risk of benzodiazepine dependence): can use Atarax (hydroxyzine) as a non-hypnotic/benzodiazepine, can use Ativan (lorazepam) also, prefer to minimize use of Xanax (alprazolam) give rapid on and off
- If looking for longer term agent: consider slow uptitration of SSRI (fluoxetine, sertraline, citalopram) or for even fast onset though not as effective can use buspirone (often used for anxiety during rapid ventilator weaning in the ICU). Can use longer acting Klonipin (clonazepam) benzodiazepine if needed
- Differential similar to altered mental status differential, worse with prolonged ICU or hospital stay and with patients who already have neurologic impairments
- Nonpharmacologic treatments: reorientation, open the blinds during the day and turn off lights at night, minimize mind altering medications, reduce overnight vital signs
- Pharmacologic treatments: IV Haldol (haloperidol) if agitated acutely or PO Seroquel (quetiapine) if more subtle though no good data
- Original “Depressed mood + SIG E CAPS” criteria (5 out of 9): sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicidal ideation
- DSM-5 criteria for major depressive disorder: must meet all 4 of these (symptoms cause clinically significant distress or impairment, symptoms not from other medical condition or medication/drug, no concern for schizophrenia/delusional/paranoid disorders, no manic or hypomanic episodes) and must meet 5 of the following 9: depressed mood and “SIG E CAPS” as above
- Initial treatment regimens: fluoxetine, sertraline, or citalopram (SSRIs) along with either cognitive behavioral therapy or inpatient chaplain as talk therapy
- First line: melatonin
- Second line: Benadryl (diphenhydramine)
- Third line: Restoril (temazepam)
Opiate Withdrawal/Methadone/Suboxone
- COWS score (Clinical Opiate Withdrawal Score) consists of 11 components performed by nursing (HR, sweating, restlessness, pupil size, joint/bone aches, runny nose or tearing not accounted by allergies or URI, GI upset, hand tremor, yawning during assessment, anxiety or irritability, gooseflesh skin
- Perform urine drug screen and consider possibility of concurrent alcohol/benzodiazepine use and withdrawal
- PRN drugs used for withdrawal symptoms: clonidine (for hypertension), Bentyl (dicyclomine, for abdominal cramps), Imodium (loperamide, for diarrhea), Benadryl (diphenhydramine) for anxiety or itching
- Methadone: can work with pharmacy to give emergency doses of methadone until psychiatry can see the patient to prevent withdrawal, monitor QTc (risk is very real), may require an opiate washout period before starting, can only increase dose about every 3 days, if on methadone chronically the inpatient pharmacy needs a faxed letter from the outpatient methadone clinic detailing the dose and last witnessed administration before inpatient doses can be ordered (other than emergency dose if clinic closed)
- Suboxone (buprenorphine-naloxone): may require an opiate washout period before starting, patient can be discharged from the hospital (or if started in any clinic) with 4 days of Suboxone to begin maintenance therapy if a psychiatric provider can see them within that time (prescriber must be have a DEA number and buprenorphine X-waiver or medication-assisted treatment certification)
- On discharge consider Narcan (naloxone) prescription
- Narcan pushed inpatient may require rapid response for nursing support and if persistent may require Narcan drip