I am soliciting the much needed help of all of your seasoned psych nurses.
I work in a busy medical/surgical/trauma ICU. We see all kind of patients with drug problems:
1) The saturday night alcohol/drug indulger who gets intubated for various reasons. They usually are extubated the next day. Some leave AMA. For a few, it is a one-time event. The staff and their families are supportive and they leave having learned a hard lesson.
2) The adolescent/young adult whose will is broken by 10 strong males and a few screaming doctors and nurses.
3) The long-term (10+ years) drug/alcohol abuser who ends up in the unit for either a severe medical or trauma-related issue. I assume that many, but not all, have some sort of underlying behavioral or psych issue. They are often heavily sedated in the beginning of their stay with benzos and opiates. (It takes large hourly doses of drugs to keep these patients down.) As they get better and are extubated, they become difficult to handle. They are not well enough to be transferred to a step-down unit and thus I am left trying to manage their behavior and treat their medical issues. And it is their behavior (and that of their families) that is driving me insane! Families expect us to force the patient to be compliant with medical care.
I've seen small doses of benzos/opiates have a rebound effect on some of these patients. This leaves them either in a stupor or agitated/anxious. It becomes hard to separate the psych issues from the medical issues. I guess we are underdosing some patients and others are just a puzzle. Confrontations happen and has little therapeutic effect. We do not have a psych unit in our hospital. We can consult psych, but they don't address withdrawal and don't give us much relief when it comes to the behavioral issues. Sometimes it takes the whole unit to manage these patients.
Is there a public or private resource somewhere that can help us? Some of my worst nights have been with detoxing patients. Our rooms are not set up for safety and it is hard to get one-on-one observation unless the patient is suicidal. :loveya:
As someone that works in a free-standing (hospital-associated) detox facility, I'm glad to read of someone in ICU that is trying to understand the medical difficulties posed by detox. Here the main scales that you should be using:
CIWA--for alcohol withdrawal. Our facility's standing orders are: CIWA 8-11 1 mg lorazapam, CIWA 12+ 2 mg lorazapam. May repeat hourly. Other standing orders include clonidine 0.1 mg available for b/p > 150/100 and metoprolol for HR > 110. We use vistaril 50 mg to combat nausea/vomiting (use IM or PO) and for anxiety and sleep. Additionally, patients generally need an IM of thiamine on admit to stave off Wernicke-Korsakoff syndrome--followed by PO administrations.
COWS--for opioid withdrawal. We alternate clonidine and tramadol for scales. Additionally, we have meds available for diarrhea, stomach cramping.
Benzodiazapine withdrawal scale--we use this with phenobarbital available for high scales--mainly we worry about seizures from this withdrawal.
SWS--for stimulants.
I would recommend that you have a MD that is familiar with these scales to set up standing orders so that you can deal more effectively with these types of patients. They aren't easy, I know!
My Psych hospital has a inpatient 5-7 day detox unit. Etoh detox protocols we use are Ativan 2mg or Librium 50mg every hour for Ciwa scales >10. Using the Ciwa, we assess every four hours under 10. If initial assessment is 10 or greater, then assess 1 hour after medication thereafter until you get it under a 10. CIWA assessment assesses for the following s/s and you score them accordingly.I would grab a CIWA and read over it. Is the pt nauseaus, dry heaving, vomiting, mild-severe tremors present, level of orientation, mild-severe anxiety, HA or head fullness, mild to severe agitation present, sweaty palms or drenching sweats, is the pt hearing, seeing, or feeling things not there. This can be as mild as lights hurting their eyes, numbness or pins needles in fingers, sounds seeming too loud. Or the A/V/T hallucinations can be as severe as hearing/seeing things not there or feeling bugs crawling on them. If they are having severe A/V/T hallucinations and do not normally have them, then they are most likely heading for deliurium. The assessment is subjective and objective. I use VS as a tool, but if they have hypertension or cardiac hx, it makes it difficult to tell, but most people detoxing from ETOH, will have elevated BP and HR. Also, we give vitamins. Every pt detoxing from ETOH gets an initial Thiamine 100 mg IM, then thiamine 100mg po, pyrioxidine 100mg po, and a MVT daily for 7 days. A lot of pts detoxing from ETOH will not have any s/s until 24-48 hours after last drink. I always ask how much they drink daily and for how long and when last drink was. The ones I generally worry about are the ones that drink 12-24 beers or generous amt of liquor daily for long period of months or years, or that amount 4 days or more a week. Opiate addicts detoxing are not a medical emergency, but they are uncomfortable. They will have severe cravings, stomach cramps, leg cramps, diarrhea, increased anxiety and agitation, dilated pupils, piloerection, and mood lability and verbal aggression. Also, if you have someone that's been on benzos for awhile are at risk for seizures and it is dangerous to be cut off all at once on their benzos. We usually titrate them down for 5-7 days and monitor for withdrawals like increased anxiety, agitation, elevated BP. The hallmark with them is tachycardia. Hope this helps! Good luck!
SlightlyMental_RN
471 Posts
As someone that works in a free-standing (hospital-associated) detox facility, I'm glad to read of someone in ICU that is trying to understand the medical difficulties posed by detox. Here the main scales that you should be using:
CIWA--for alcohol withdrawal. Our facility's standing orders are: CIWA 8-11 1 mg lorazapam, CIWA 12+ 2 mg lorazapam. May repeat hourly. Other standing orders include clonidine 0.1 mg available for b/p > 150/100 and metoprolol for HR > 110. We use vistaril 50 mg to combat nausea/vomiting (use IM or PO) and for anxiety and sleep. Additionally, patients generally need an IM of thiamine on admit to stave off Wernicke-Korsakoff syndrome--followed by PO administrations.
COWS--for opioid withdrawal. We alternate clonidine and tramadol for scales. Additionally, we have meds available for diarrhea, stomach cramping.
Benzodiazapine withdrawal scale--we use this with phenobarbital available for high scales--mainly we worry about seizures from this withdrawal.
SWS--for stimulants.
I would recommend that you have a MD that is familiar with these scales to set up standing orders so that you can deal more effectively with these types of patients. They aren't easy, I know!