Alcohol Intoxication.

Every facility has their own protocol. The one that my facility uses has an option for Librium only, which seems to work on the 2 or 3 pts I've had on that protocol. (Usually, my detox pts are intubated & sedated - ICU.) *shrugs*

I mostly only see an order for Librium either Q8 or Q6... I often have to fight for a PRN ativan order for the ones that are bad, but even then it's only Q6 PRN. Some docs manage detox better than others, that is for sure.

I work at maryland general, are protocol is mostly librium q4

If the person is a chronic ETOHer then you might need a stronger or different benzo, but Librium should do the trick, you don't want to have to many prescribed or people may get confused as to what to give when and you also don't want to over sedate. If the pt responds well to Librium then great, but if not then they may switch to Ativan or Valium. Depends on hospital policy on ETOH withdrawl and also how bad the pt is.

It sounds about normal to me. The two beer thing , well, as I look back into my childhood, we used to give dad a beer every 6 hours the first day, and like twice the second day, and then one time the third day.. that's how we detoxed him. lol

I know it's not funny, but I can snicker now because he's been sober for over ten years. Little did I know back then that there were several times we should have taken him to the ER. Thank God all those DT's never caused permanent damage.

I suggest that you start using an evaluation tool called a CIWA scale. The patient's responses will guide the nurses on whether or not this patient needs more medication, different medication or a higher / lower level of care. There's a good article with the eval tool included in this link: http://www.aafp.org/afp/20040315/1443.html

I've used it more than once as my evidence to get a detoxing patient moved to a higher level of care. Keeps the patient safe, keeps the staff safe. We found it so effective that it became part of our ETOH standing orders.

I suggest that you start using an evaluation tool called a CIWA scale. The patient's responses will guide the nurses on whether or not this patient needs more medication, different medication or a higher / lower level of care. There's a good article with the eval tool included in this link: http://www.aafp.org/afp/20040315/1443.html

I've used it more than once as my evidence to get a detoxing patient moved to a higher level of care. Keeps the patient safe, keeps the staff safe. We found it so effective that it became part of our ETOH standing orders.

This is what we used primarily at my first job, unfortunately down here it GA it appears no one has heard of it. For half of our DT'ers we are lucky most people ever recognize that is what is going on until they wind up in the ICU. I may have to print and present the CIWA down here to save our hospital some valuable ICU time. If we could detox frequently in a small rural hospital on the floor every week, there is no reason we can't be doing it effectively down here.

I will say on our detox protocol (there not here) we had a choice of three different meds to give per the scale. Ativan, Valium or Librium. It was up to the doc to choose the correct one for the patient, but we most often were giving Ativan.

Tait

Last place I worked at didn't use Librium or Ativan. If alcohol withdrawal scale hit a certain point (I forget exact details), you would give the pt po valium 20mg for three consecutive hours and then proceed with 10 - 20 mg each time after that depending on scores for a maximum of 200mg in 24hrs. I guess the idea was to get the pt "drunk" on something else. However,I confess to preferring the librium ATC with ativan PRN regime.

We usually use Librium ATC with Ativan PRN. The trick is getting less experienced people to recognize the symptomology of DTs and responding properly. I had a newer nurse one time comment to me in the med room that "Mr. Smith just wants more narcs...he told me since his hands are starting to shake that I need to give him Ativan!" This on a man who regularly downed over a liter of vodka or whiskey daily. I told her to look up alcohol withdrawal symptoms after she gave him the Ativan NOW.

I work in psych ER and so we get the drinkers sent to us A LOT. We do CIWAs on every patient that we suspect or have report from the patient of ETOH use regularly-- We have psych docs that specialize in CD.....I have never even once used librium, not here or at my other job in psych inpatient. I wonder if it's a NY thing or the city I am in or what but we always use Ativan. Have used valium a couple of times. Be sure to use a full CIWA-- meaning with ortho BPs....we get patients who were on CIWAs in med ER and for some reason their CIWA sheets don't include the Ortho BPs....sometimes the changes might be seen in the vitals for a while but not in the visible signs. It is important for all the nurses to be aware of...as you said many newer nurses might not recognize withdrawal until really far into things when you have DTs or seizures and don't realize that a person can DIE from alcohol withdrawal as well as from benzo withdrawal if the person is on a lot/taking a lot.

Here is a pretty good article on alcohol withdrawal syndrome for nurses:

http://ccn.aacnjournals.org/cgi/reprint/25/3/40.pdf

It explains the effects of alcoholism on the central nervous system and why abrupt discontinuation of drinking (without medical supervision, including appropriate medication) is so dangerous. Managing symptoms is more than just minimizing the discomfort the patient is feeling, or the patient seeking the effects of benzos. Any nurse that cares for these patients needs to familiarize him or herself with the CIWA scale.

I don't particularly relish the idea of having an ETOH'er, but I must say once I learned more about what the patient's body is going through I had more empathy for them and became much better at managing the symptoms.

Our AWD protocol uses Ativan PRN according the Riker Sedation-Agitation Scale.

I'm not aware of any new research, but my pharmacology text states that administering other benzos with short half lives such as Librium on a fixed schedule is an effective treatment strategy, but that using PRN medication according to symptoms permits a quicker withdrawal.