Category Archives: protocols

CIWA Protocol Precautions

The post entitled “CIWA Demystified” is one of the most popular on this blog. This type of symptom triggered therapy for alcohol withdrawal applies some degree of objectivity to a somewhat subjective problem. However, it is possible to take it too far.

A retrospective review of registry patients who received CIWA guided therapy was performed. A total of 124 records were reviewed for appropriateness of CIWA useand adverse events. They found that only about half of patients (48%) met both usage criteria (able to communicate verbally, recent alcohol use). And 31% did not meet either criterion! There were 55 nondrinkers in this study, and even though 64% of them could communicate that fact, they were placed on the protocol anyway! Eleven patients suffered adverse events (delirium tremens, seizures, death). Four of them did not meet criteria for use of the protocol.

Bottom line: In order to be placed on the CIWA protocol, a patient must have a recent history of alcohol use, and must be able to communicate verbally. Some physicians assume that patients with autonomic hyperactivity or psychological distress are withdrawing and order the CIWA protocol. This can  cover up other causes of delirium, or may make it worse by administering benzodiazepines. This represents inappropriate use of the protocol!

Related post: The CIWA Protocol Demystified

Reference: Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin Proc 83(3):274-279, 2008.

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The CIWA Protocol Demystified

What exactly is the CIWA protocol?

It is a tool used commonly in the US that helps clinicians assess and treat potential alcohol withdrawal. A significant amount of injury in this country is due to the overuse of alcohol. A subset of these patients are admitted and do not have access to alcohol. They may begin to withdraw within a few days, and this condition can lead to dangerous complications.

The Clinical Institute Withdrawal Assessment measures 10 items that are associated with withdrawal:

  • Nausea / vomiting
  • Anxiety
  • Paroxysmal sweats
  • Tactile disturbances (itching, bugs crawling on skin, etc)
  • Visual disturbances
  • Tremors
  • Agitation
  • Orientation
  • Auditory disturbances
  • Headache

All items are measured on a scale of 0-7 with the exception of orientation, which uses a scale of 0-4. All subscores are tallied to arrive at the final score.

The total score is used to determine whether benzodiazepines should be given to ameliorate symptoms or avoid seizures. Typically, a threshold is selected (8 or 10) and no medications are needed as long as the patient is under it. Once it is exceeded, graduated doses of lorazepam or diazepam are given and vital signs and CIWA scores are repeated regularly. The protocol is discontinued once the patient has three determinations that are under the threshold.

The individual dosing scale and monitoring routine varies by hospital. Look at your hospital policy manual to get specifics for your institution.

For a copy of the CIWA scoring criteria, click here.

Tomorrow, precautions when using the CIWA protocol.

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The Post-Crunch Debriefing

Trauma centers generally design their trauma teams around the type and volume of injured patients they receive. There must be sufficient depth of coverage to handle multiple “hits” at once. But even the best planning can be overwhelmed by the occasional confluence of the planets where multiple, multiple patients arrive during a relatively short period of time (the “crunch”).

As the reserve of available trauma professionals to see new, incoming patients dwindles, it sometimes even becomes necessary to close the center to new patients. Once those who have already arrived have been processed, the trauma center can open again.

This scenario, while hopefully rare, unfortunately introduces a huge opportunity for errors and omissions in care. There is much more clinical activity, lots of patient information to be gathered and processed, and many decisions to be made. How can you reduce the opportunity for these potential problems?

Consider a “post-crunch” debriefing! Once things have quieted down, assemble all team members in one room. Systematically review each patient involved in the “crunch”, going through physical exam, imaging, lab results, and the final plan. It’s helpful to have access to the electronic medical record during this process so everything that is known can be reviewed. Make sure that all clinical questions are answered, and that solid plans are in place and specific people are assigned to implement them. And most importantly, make sure everything is properly documented. Remember:

“Work not documented is work not done!”

Once you’ve reviewed all of the incoming, don’t forget your patients already in the hospital. Significant issues may have occurred while you were busy, so quickly review their status as well. Chat with their nurses for updates. Make sure they are doing okay.

Then prepare yourself for the next “crunch”!

Related post:

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Massive Transfusion And Tranexamic Acid (TXA)

Tranexamic acid has been in use for decades, just not for trauma. The CRASH-2 trial was a massive multi-country study showed that there was a slight mortality reduction from 16% to 14.5% in trauma patients who had or were at risk for “significant hemorrhage.” Moreover, there was no difference in vascular occlusive events, blood product transfusions, or need for surgery. Sounds great, right?

The MATTERs trial was initiated by the US military and tried to address some of the perceived shortcomings of CRASH-2 and found an absolute mortality reduction of 6.7%. But it also showed DVT rates that were 12x higher and PE rates 9x higher when this drug was given.

Since those two studies, a significant number of critiques have been published, as well as some additional research. Unfortunately, this has only served to cloud the picture. TXA is very inexpensive and readily available, so there has been a significant move to adopt both in the trauma center, as well as during prehospital care prior to arrival.

The trauma group at Denver Heath published a study of 232 patients with a 20% mortality rate from their injuries. They identified three subsets of patients based on their fibrinolytic response upon presentation to the hospital: physiologic fibrinolysis (49% of patients), hyperfibrinolysis (28%), and fibrinolytic shutdown (23%).

They found that mortality significantly increased in those receiving TXA who were physiologic or hyperfibrinolytic, but unchanged in those in shutdown. They cautioned that giving this drug before the patient’s fibrinolytic status was known could contribute to mortality.

Bottom line: So confusing! And many centers already include TXA in their massive transfusion protocol. Most have not seen unexpected mortality after giving the drug, so the jury is not in yet. Each trauma center should weigh the currently known pros and cons, and decide whether they are “believers” or not. Carefully review all mortalities and thrombotic complications after administration to see if there was any relation to the use of TXA.


  1. Massive transfusion protocols and the use of tranexamic acid. Current Opinion Hematol 25(6):482-485, 2018.
  2. Tranexamic Acid is Associated with Increased Mortality in Patients with Physiologic Fibrinolysis. J Surg Res 220:438-443, 2017.
  3. CRASH-2 Study of Tranexamic Acid to Treat Bleeding in Trauma Patients: A Controversy Fueled by Science and Social Media. J Blood Transfus Article 874920, 2015.
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TEG And Your Massive Transfusion Protocol

Thromboelastography (TEG) and its fraternal twin rotational thromboelastometry (ROTEM) are relatively new toys in the trauma community. They allow for (somewhat) rapid assessment of clotting function, and allow the trauma professional to surmise what products might push abnormal clotting characteristics back toward normal.

Many trauma centers already own this technology due to its use by non-trauma services. But there have been a growing number of research presentations on the topic over the last five years, and many centers are clamoring to buy these units for use in their MTP.

But remember, new technology is usually expensive, and isn’t always all it’s cracked up to be. TEG and ROTEM require a (often-times) new machine and a never-ending supply of disposable cartridges for use, like your ink jet printer. Some hospitals are reluctant to provide the funds unless there is a compelling clinical need.

Surgeons at the University of Cincinnati compared the use of TEG with good, old-fashioned point-of-care (POC) INR testing in a series of major trauma patients seen at their Level I center.

Here are the factoids:

  • This was a retrospective review of 628 major trauma patients who received both TEG and POC INR testing using an iSTAT device over a 1.5 year period
  • Median ISS was 13, and there were many sick patients (20% in shock, 21% received blood, 11% died)
  • INR correlated with all TEG values, with better correlation in patients in shock
  • Both INR and TEG correlated well with treatment with blood, plasma, and cryoprecipitate
  • Processing time was 2 minutes for POC INR vs about 30 minutes for TEG
  • Charges for POC INR were $22,000 vs $397,000 for TEG(!!)

Bottom line: Point of care INR testing and TEG both correlated well with the need for blood products in major trauma patients. But POC INR is much cheaper and faster. Granted, the TEG gurus will say that you can tailor the products administered to meet the exact needs of the patient. But in all my travels, I’ve see very few centers that have fully, effectively, and contemporaneously incorporated TEG or ROTEM into their massive transfusion protocol from start to finish.

The area where TEG and ROTEM are most helpful are in the “mop up” phase at the tail end of the MTP. These tools allow trauma professionals to determine exactly which products are needed to normalize parameters, and they frequently diverge from the 1:1:1 to 1:1:2 ratios at that point to achieve this.

If you don’t have one of these toys yet, make sure that you have a very good clinical reason to do so. If you do, think very carefully about how you can meaningfully incorporate it in the massive transfusion process and write it into your protocol.

Reference: All the bang without the bucks: defining essential point-of-care testing for traumatic coagulopathy. J Trauma 79(1):117-124, 2015.

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