Alcohol Withdrawl

[estrogen]

Thank you! My father just died from alcoholism....well alcoholic cirrhosis. Did I like the disease/ addiction? No! But it is an addiction and he did try to fight it...but just because we don't like how someone got sick, doesn't mean we have to care for them any different than any other sick people or let them "feel" DTs etc to teach them a lesson.....Heck...I don't like smoking, but take care of quite a few COPDers, lung Ca etc and I've never withheld or waited on giving a breathing treatment or given care any different...it is none of our business...Taking care of patients is our business. Yes we can try to educate and reinforce good heath behaviors, but you cannot force a person clean!

AMEN to that!!! Thank you and I am sorry for your loss.

[Dinith88]

I hate taking these patients. Aside from the seizure stuff, the ones that develope withdrawal-induced psychosis and try to get out of bed, pull at lines and tubes, become combative, etc. drive me freakin NUTS.

My favorite way to deal with DT's is tubing and sedating them. We have no standard protocol for treating DT's.

[Mama Val, ASN, RN]

Detoxing a ETOH abuser is rough not knowing if they are playing the game to get drugs or if they really do see snakes crawling out of their bellybutton.

CIWA scales are a big help when they are used properly, esp for HCPs who don't deal with drinkers to often. My first dealing with a full blown ETOH detoxing older lady was horrid, I was not prepared at all. I was 6 months pregnant and she was mentally GONE.. alcoholic psychosis, having audio and visual hallucinations, 4 pointed to the bed because she kept tring to pull out her IVs, catheter and she would claw her ABD dressings. She ended up getting out of her restraints and running down the hall. She was tackled by security. I felt so bad afterwards, I was only giving her 25mg Librium every 2-4 hours. The order was 25- 100mg Q 2-4 hrs. I was way under dosing her, not that it would have amade a huge difference but she may have calmed down a little, her BP may have come down sooner. I've learned a lot since.

We use Tranxene at the jail- set dose on a set schedule- lets be honest it kinda sucks if your that patient and its in between med times.

At Detox we do the Librium dosing with Ativan or Atarax mixed in as needed.

We can go up to 600mg Q 24hrs in our patients but if the ANP oks it we can bump it 800mg Q 24hrs. Our ANP will tell you that you can never overdose somebody on Librium, I beg to differ. The problem I have is when you give a person their meds and they go out for a smoke walk off, then come back 4-5 hrs later drunk as a skunk and wanting back in. How much medication do you give the person who is in active DTs, extrem tremors, tonguing waging the whole 9 yards who you know will just walk outta here sooner before later, and yet give them enough to keep them from having a seizure in the bathroom.

Clonidine at both place for increased BP as needed.

[Aellyssa]

hi,

let me make it quite clear where i am coming from. atod (alcohol, tobacco & other drugs) is a clinical interest of mine and an area in which i teach. one of the first things that i say to my students is that they are never to use the term alcoholic or drug addict(druggie) :angryfire . these terms are negative stereotypes and merely serve to stigmatise patients. for that matter i don't allow the students to use an "ic" word (ie asthmatic, diabetic) except as an adjective ie descriptive term. naming a person as an "ic" puts the disease first and not the person ie it is a person with a drug/etoh dependency problem, a patient with asthma etc.

secondly etoh dependence is viewed by most people working in the area as a syndrome not as a disease, and therefore approaches to treatment may be different than in usa as we tend to move away from the bio-medical model. we also have a harm minimisation approach in our care for people who use atod. this means that we recognise that people will continue in their use and we seek to minimise the harm that they can do to themselves in their usage. of course, abstinence may be the final goal but unless the person wants to change they won't. furthermore many researchers in the field do not espouse the theory "of once a user, always a user' so the generally held view of a "recovering alcoholic" even after years of abstinence places them in a difficult situation as it takes away the person's autonomy. that is not to say it isn't true for some people, just not for all.we could debate this for hours with no true resolution.

so what is alcohol withdrawal? etoh is a depressant of the cns. this means that it depresses neuronal activity. furthermore there is the issue of tolerance ie you need to drink more to get the same effect - thus the person drinks an increasing amount of etoh. thus the cns is depressed even more. in order to function, the cns sends more and more nervous impulses to counteract the etoh. thus there is neuronal hyperactivity. suddenly the person stops drinking. but the cns is still sending out heaps of impulses with nothing to stop it. it's like bursting a dam. it is this hyperexcitability that causes the clinical features of etoh withdrawal ie tremors, hallucinations and seizures. and yes, it can cause death. delerium tremens is the final and most life threatening stage of etoh withdrawal. it is nearly always complicated by co-morbidities such as cardiac conditions. it is not what most people call the dts.

so how do you treat it? in adelaide, south australia - the drug and alcohol services council has issued guidelines to all hospitals, doctors and nurses. they can be accessed at http://www.dasc.sa.gov.au/resources/documents/atod_nursing_quick_clinical_reference.pdf

basically it goes like this;

1. all patients have a drug & etoh assessment when they are admitted to hospital.

2. etoh intake is measured by standard drinks (10gm etoh). every pub has the standards for these up in their establishment.

3. if the person has a history of >80mg of etoh a day, then they are at risk of etoh withdrawal.

4. they are then observed using an etoh withdrawal chart with 1 hourly obs

5. if that score is >13 they are started on a regime of diazepam (to calm down the cns)

6. this continues until they reach a score below 13.

hope this helps.

cheers,

aellyssa

[Mama Val, ASN, RN]

Aellyssa,

I agree with you people misuse the phrase "DTs" as catch all for ETOH withdrawals. I have nurses who tell me "The patients is having DTs but not shaking" or "they have a history of DTs and they get the shakes".They are the same thing, tremons/tremors= shaking or twitching of extremeties ( or a positive tongue wag). Hallucinations, diaphoresis, agitation, anxiety and increased BP/HR are not DTs, they are co S/Sx.

You wait until 13, we start at 10. What about their BAC/PBT levels do you have a certain criteria?

If the client is intoxicated, BAC/PBT above 0.125 but in active withdrawals, above a 10 on the CIWA, and has a HX of seizures we will start medicating them ASAP. If not they have to be either sober and in active withdrawls or in active withdrawals and with a BAC/PBT of 0.125.

I am intrested in what you do down there.

What about your freq fliers who know the CIWA by heart and answer 7s for anxiety and agitation but are sitting calmly, hands in lap, resp @ RRR. How do you deal with those clients?

[Aellyssa]

Hi Mama Val, The Clinical Guidelines could tell you the most of how we treat it. The DASC Website is a fount of knowledge plus there seems to be a number of really good ATOD websites in Australia. I can't answer your query about the frequent fliers if I understand your term - ie those who come in frequently. That is a difficult one and I guess you would wonder why they were there. Diazepam perhaps. How do you handle it? Aellyssa

[Mama Val, ASN, RN]

We go thru spurts of policy changes:

This client can come in only once every 7 days then once every 14 days, and so on..

Then we tried, if the client leaves AMA we ban them for 30 days, ..

Now we are on contracts, the client has to sign a contract as soon as they are sober. They will agree by written contract to stay until certain criteria are met, for that client, if they leave before all objective are addressed then we can restrict them twice for 7 days, then twice for 14 days, then twice for 21 and finally they are restricted for 1 month periods after that.

We only have 1 nurse and 16 beds, our regulars / frequent fliers suck up the bed space and have no intention of trying to change. We don't use Valium or Haldol or they would never leave. Those people that have never been to Detox and really want to change/ still have a chance of recovery, can't get in. Since we take federal money per policy we have to take everybody that come to our door, except sex offenders that is.

I printed out your reference packet, thanks.