Impact of Traumatic Brain Injury on Clinical Institute Withdrawal Assessment Use in Trauma Patients: A Descriptive Study

Abstract

Background Alcohol withdrawal syndrome (AWS) and traumatic brain injury (TBI) present with similar signs and symptoms, yet their treatment strategies differ greatly. AWS treatment includes the Clinical Institute Withdrawal Assessment (CIWA) protocol, which grades withdrawal signs and symptoms. A major purpose of CIWA is to guide the addition and titration of central nervous system (CNS) depressants, most commonly benzodiazepines. Conversely, best practice is to avoid these same CNS depressants in the setting of TBI. Thus, patients with TBI presenting with AWS risk may receive undesirable interventions that could worsen outcome. Objective To describe the relationship of TBI diagnosis with CIWA protocol scores and intervention implementation. Design Retrospective cohort observational study. Setting Single university‐based, level one trauma center. Patients Three hundred seventy‐five patients with head trauma or AWS classification, identified through the trauma center's trauma registry. Interventions CIWA protocol and related medication use. Main Outcome Measures Frequency of elevated CIWA score, length of CIWA administration, and medication administration incidence were abstracted from patients' medical records. Results The percentage of elevated CIWA scores increased significantly with TBI severity, from 4.5%(0‐60) in the No TBI group, up to 12.5% (0‐36) in the Mild TBI group, 27.1% (0‐57) in the Moderate TBI group, and 50.0% (14‐77) in the Severe TBI group. Nominally, lorazepam use showed a similar pattern of escalation with TBI severity, but it did not reach statistical significance. Haloperidol use did significantly escalate with higher TBI severity. No group differences were observed for total lorazepam equivalents or length on the CIWA protocol. Conclusions TBI diagnosis and higher TBI severity level correlate with higher CIWA scores, but neither increased nor decreased benzodiazepine usage was observed. Antipsychotic use did escalate with TBI diagnosis and severity. The risks versus benefits of minimizing benzodiazepines in patients with TBI who are at risk for AWS warrant future study.

Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

“…The mMINDS assessment has been validated in medical ICU patients. 30 32 The advantage of mMINDS is that it does not require the patient to answer questions. Instead, it assesses pulse, blood pressure, and the presence of tremor, sweating, hallucinations, agitation, orientation, delusions, and seizures to analyze AWS severity.…”

“…In a single-center study of ICU patients, CIWA-AR was not assessed in 44% of patients, due to intubation 29. Similarly, some conditions, such as traumatic brain injuries, may falsely elevate CIWA-AR scores, so the scale must be cautiously interpreted in surgical and trauma patients 30. There is limited evidence suggesting that the CIWA-AR scale may be augmented by simultaneously following the Riker Sedation Agitation Scale, a sedation scale commonly used in many ICUs, but this work has primarily been aimed at guiding treatment strategies rather than monitoring for AWS 31…”

“…The mMINDS assessment has been validated in medical ICU patients 30 32. The advantage of mMINDS is that it does not require the patient to answer questions.…”

Comparison of phenobarbital monotherapy to a benzodiazepine-based regimen for management of alcohol withdrawal syndrome in trauma patients

“…In addition, obtaining a CIWA score requires patients to communicate, which could be difficult for patients with certain injuries (e.g., traumatic brain injury or significant facial fractures). [20][21][22][23] Use of other severity symptom scores that overcome these limitations such as the Minnesota Detoxification Scale would have required significant personnel training and creation of documentation tools in the EMR, limiting a timely implementation of the new protocol. As for dosing, given our team's minimal use of PHB before protocol initiation, PHB's long half-life, and concern for PHB-induced respiratory depression with higher doses, we chose a more conservative regimen.…”

“…We chose not to use CIWA because it has not been validated in trauma patients and underlying injuries could falsely elevate CIWA scores, causing unnecessary PHB or BZD administrations. In addition, obtaining a CIWA score requires patients to communicate, which could be difficult for patients with certain injuries (e.g., traumatic brain injury or significant facial fractures) 20–23 . Use of other severity symptom scores that overcome these limitations such as the Minnesota Detoxification Scale would have required significant personnel training and creation of documentation tools in the EMR, limiting a timely implementation of the new protocol.…”