Delirium tremens, level of care?

Lev, MSN, RN, NP · Jun 28, 2015

What was his mg and k?

hybr1d · Jun 28, 2015

What are those short for? For me mg = milligram and k=kalium (swedish potassium).

K+MgSO4, BSN · Jun 28, 2015

Magnesium

hybr1d · Jun 28, 2015

I don't know. Didn't look in the journal since it wasn't my pt.

canigraduate · Jun 28, 2015

You can handle an alcoholic on a medical floor pretty easily, unless they start to tank. It's hard knowing when that is going to happen without some sort of standard tool. In the US, we have a couple of tools called SAS and CIWA that help us measure the level of withdrawal and give us specific protocol orders to manage it. Once the patient's withdrawal level scores above a certain number, then we farm them out to the ICU.

Basically these tools measure different signs/symptoms of withdrawal such as tremors, sweating, LOC, level of activity, level of agitation, elevation of vital signs, presence of auditory/tactile/visual hallucinations, etc. Per the protocols, we give a dose of lorazepam based on the scores. When I worked on the floor I was giving up to 4mg of lorazepam every two hours. When I worked in the ICU I had a hard core drinker who was on an 8mg/hour lorazepam drip plus up to 4mg bolus hourly. He was pretty wild.

I have seen withdrawal symptoms as early as 4-6 hours after the last drink, although most of the symptoms have started 24-48 hours later. If the person has been solely drinking alcohol without eating or drinking anything else, I have seen quite a few cardiac problems from electrolyte imbalances. I have only had one person die from DTs, and he lied to us and said he didn't drink. We were medicating him for the wrong thing.

calivianya, BSN, RN · Jun 28, 2015

We usually manage them in intermediate here. My first hospital was lower acuity across the board, so they were managed in ICU. I almost never see them in ICU anymore. Assuming they are getting the right doses of Ativan per CIWA protocol, they shouldn't deteriorate to the point that they need ICU care.

I am curious what your protocol was that he got to that point. Do you score the patient based on symptoms and give correspondingly larger doses of Ativan more frequently based on the protocol?

hybr1d · Jun 28, 2015

Alright, back from a little nap :-) I don't think we have these protocols, not us nurses anyway. I've never heard of them. I have read the swedish guidelines regarding delirium tremens before since I'm a sponge regarding information but yeah, this is the first patient I've heard of at the ward who's been in this state. I work at a small countryside hospital but the regions main hospital has better suited wards (psych detox wards) for this and I believe that's where they end up normally. I'm sure they do have that kind of guidelines there. If an intox comes to the hospital generally they are supposed to be monitored @ ICU since we don't have the manpower at night to give that kind of acute care for any lenghty time on the medical wards.

I'm learning a lot from what you write so I'm all ears here. I know the patient was given oxazepam per os, which is considered secondary choice to diazepam. I don't know what dose oxazepam but it should've been 25 mg tablets x4 + 10 mg as needed until patient is sleeping according to guidelines for alcohol withdrawal but I highly doubt pt was given that high dosages, I'll see in the narcotics journals when I'm back from my vacation. Guidelines for delirium tremens here is diazepam rectally or in drip or propofol sedation. I wish I knew more but I didn't dare go read the journal though I wanted to so I could set my mind at ease, the regulations are tight for a reason. I really really wonder what went wrong. The doctor hadn't come up to see the pt but must've known of the situation, when she finally came pt was already in asystole. Just have this feeling this could've been avoided. I mean oxazepam per os instead of diazepam rectally or iv when someone is seeing cats, 40 degree fever and is going totally wild? I really hope my colleague wont end up in the line of fire in the aftermath.

calivianya, BSN, RN · Jun 28, 2015

I just tried to find you a sample protocol that matched my hospital's, but I looked through four different protocols and they were all different on their dosing. I like this one that I found because it explains the CIWA scale, too.

The gist of the one my hospital uses is if the withdrawal symptoms are mild, you reassess withdrawal symptoms and give 2mg Ativan q4h. If they are moderate, you assess/give 2mg Ativan q2h. If they are really in hardcore withdrawal, we will be giving Ativan every hour. I do agree that it's a little much to have one of these on a general medical floor... they should at least be somewhere with a max of 3-4 patients per nurse because they can require q1h interventions.

hybr1d · Jun 28, 2015

Thanks! Gonna save that one. Yeah, it's enough if one patient gets really ill at night and then I can't manage much else but that, I have 18 patients total to care for. Us nurses aren't really allowed to leave our wards at night even if to help eachother out but we sometimes have to. Realise everytime sometime new happens how much there is left to learn.

annie.rn · Jun 28, 2015

That sounds like an awful situation and one that could perhaps have been avoided w/ a better protocol in place. I agree it could have been an electrolyte issue but I would assume those would have been checked in ER and replaced if critical enough to cause dysrhythmia. Perhaps he seized and aspirated?

To answer your question, a pt. going through withdrawal can be handled on a medical ward IF they are treated aggressively w/ benzos from the get go to keep them from going into life threatening DT's. This is also assuming the pt.'s baseline labs are decent. If electrolytes, ammonia level, clotting are way off I would want that pt. on a monitored unit (step down or ICU).

If a pt. is needing q 1-2 hr. IVP meds I feel they are no longer a candidate for a medical unit. You just can't keep up w/ that safely and have up to 5 other patients. I remember having this situation once when I was charge and I was trying aggressively to get the pt. transferred out but the resident was dragging his heels. A staff neurologist came to see the pt. and promptly ripped the resident a new one. She was very upset that a pt. requiring q 1-2 hr. IV Ativan was not in the ICU. I remember her saying to him something like, "this is nothing to play around with. This is a medical emergency! This pt. could start seizing and die." Pt. was quickly sent to the ICU and I was quite relieved.

Enjoy your vacation and when you are back, you'd enjoy reading about the protocols we use. I personally love the CIWA scale/protocol b/c you can start it right away if you suspect possible withdrawal and avoid a lot of heartache for everyone involved.

You sound like a very good, conscientious nurse :-)

annie.rn · Jun 28, 2015

Thanks! Gonna save that one. Yeah, it's enough if one patient gets really ill at night and then I can't manage much else but that, have 18 patients total. Us nurses aren't really allowed to leave our wards at night even if to help eachother out but we sometimes have to. Realise everytime sometime new happens how much there is left to learn.

Wow! 18 patients w/ one tech. That's incredible. Definitely wouldn't want a withdrawing pt. on the unit in that case. No way one person could take care of all that.