Case study...

[Music in My Heart]

So this isn't a specific case study nor does it come from a single patient... it's an amalgamation of cases with a bit of poetic license tossed in... but it may still be helpful...

Please, experienced nurses, forgo the urge to post before the learners have the opportunity... by all means, though, chime in to respond to them (and to correct me as needed).

Here's the scenario...

Pt found down on the sidewalk by EMS... No hpi available... GCS=5 on their arrival, improves to GCS=12 by arrival to ED...

Pt is a 30-something, well-developed male... uncooperative but not combative... strong odor of alcohol... vitals are WNL, FSBG=120...

We have venous access, airway is intact, PERLA 4 but sluggish, moderate hematoma R occiput...

Basic trauma labs have been drawn...

Docs say, "we need to get him to the scanner...", what do you say/do... Questions, thoughts, concerns?

I usually pick cases that have something interesting about them or that teach me something.

For this one, it about helping students think about the risks and practicalities of getting a patient to/from the scanner... the risk to the airway, the risk for falling off the table, and the low probability of successfully scanning him to begin with... It's really hard to get the drunks to hold still long enough to get scanned.

Sometimes I travel with another person as backup in case I'm concerned that they're going to get feisty. In this case, I also had restraints on all four extremities but hadn't fastened them. I had them on and ready just in case.

Since you brought up DTs...

Is a drunk guy at risk for DTs? What signs do you see that tip you off that DTs are a concern? And how do you treat the patient?

[thehumbleRN]

Ok so my thought was just that it's an assumption that this is a one time thing. I don't work in an ER but on a tele unit and so although I'm newer, I have had 2 etoh pt's. They are difficult to say the least. So I'm just wondering if he's not coming down from being drunk for a while because of his symptoms. Usually don't see someone not holding their own, maybe they are crashing....or another thing I suspect is drug use in conjunction with the alcohol...which was my first thought.

Now that I see your process for case studies though, I'm totally overthinking it but the above thoughts did cross my mind. I love to talk to nurse stories because I always learn alot!

[applejackcrunch]

Since you brought up DTs...

Is a drunk guy at risk for DTs? What signs do you see that tip you off that DTs are a concern? And how do you treat the patient?

(Not a nursing student yet but I love reading these and trying to work through all of the thought processes that are posted, it's fun!)

Since he's drunk he wouldn't be at risk for withdrawal symptoms, correct? Didn't see anything about a BAC but I first assumed that the strong odor of alcohol means it would be pretty high- but then again, without knowing where the odor is coming from one could assume he's spilled some on his clothing as well. And even if he was having DTs, would the sedation put that concern to rest for now? I'm reading the wiki page (I know, I know- cringe...) and I see that it's treated with benzos- so sedation is treatment for DTs, right?

I post these because they (hopefully) provide a view from the real world... Where time matters.

We check EtOH levels but they don't result that fast... And don't really impact our care unless they're very low and don't jive with our initial assessment.

I guess I could assume that he simply spilled it on himself but generally speaking, when a guy acts drunk and smells drunk, he is drunk. And no, alcohol withdrawal is generally delayed by 12 to 48 hours after they stop drinking.

Nothing wrong with Wikipedia if you are mindful of your source. Yeah, we treat alcohol withdrawal with Valium and phenobarbital. Sometimes, very high doses given every few minutes... A ticket to the ICU.

The alcohol withdrawal folks are (a) sober, (b) tachy, and © tremulous... And often hallucinating

[Esme12, ASN, BSN, RN]

NOw that we are on the subject...many places in my area of the country use CWIA protocol...the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) revised scale is a validated 10-item assessment tool that can be used to quantify the severity of alcohol withdrawal syndrome, and to monitor and medicate patients going through withdrawal.

We use a combination and choice of drugs based on the patients assessment.

PRN administration

Chlordiazepoxide (Librium), 50 to 100 mg

Lorazepam (Ativan), 2 to 4 mg

Diazepam (Valium), 10 to 20 mg

or a fixed schedule:

Chlordiazepoxide, four doses of 50 mg, then eight doses of 25 mg

Diazepam, four doses of 10 mg, then eight doses of 5 mg

Lorazepam, four doses of 2 mg, then eight doses of 1 mg

Here is an example of CWIA protocol in my area....http://www.nahq.org/uploads/apps/files/ETOHWithdrawlGuideline.pdf

I found this on up to date online...http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes

[emtb2rn, BSN, RN, EMT-B]

We use CIWA with regularly scheduled librium along with prn backup. Ativan is sometimes added depending on the patient.

[thehumbleRN]

Oh thank you sooooo much for the resources!!!!!!! I am so grateful!!!! Someone post a new case study!!!