Alcohol Withdrawal

[Indy, LPN, LVN]

My patient for the last two nights was in withdrawal. Now I've seen this before, but this was the most severe case I've seen. He came in with chest pain (hurt all over actually) and had a positive stress test (how you can read it when they shake all over is beyond me) so he was supposed to wait out the shakes on tranxene and have a cardiac cath someday.

Okay. So the original story was that he'd fallen off the wagon after ten years of being clean, so they put him on four days of BID tranxene. In the first two I dunno what he did. The third day, he pulled out a foley, wouldn't stay in bed, pulled out several IV's and bled all over the place repeatedly. Very unpredictable. The fourth day, I came to work and I gave his -what was ordered as the last dose- of tranxene. He got haldol right before my shift, then I gave ativan later on, and at two AM figured out I had inadvertently got his prn's twisted so that I couldn't give anything else till 5 am, all I had left for PRN meds was phenergan and dilaudid. So I gave dilaudid, that worked till 5 am. Did a lot of talking, some handholding, general mollycoddling and such. Oh yes, he also got tylenol for his fever and OJ with his iron pills.

I come in the next night, day five for this patient. Has had the haldol I gave at 5 am, one dose of ativan (1mg) and 2 mg of dilaudid. That's it folks, and boy did he show it. Curled up in a fetal position under five blankets, begging for more blankets, skin hot but fever won't show on my thermometer, (I swear that thing is broken) shaking so hard his teeth rattled. I gave his haldol first since it was overdue (1.25mg q 12 hours), and it's like 1/4 of a ml so I really think he bumped me and the haldol wound up ON his arm and not in the IV. Can't tell though, 'cause I keep thinking I can see in the dark. Gave 1mg IV ativan next, about 10 minutes and two blankets later. I really didn't want to give him any more blankets!

An hour later I hadn't done more than vitals on my other patients. Gave his evening meds, lopressor, tylenol even though fever didn't register, took half his blankets off and I couldn't get out of this man's room. Had to squat on the floor, hold his hands in mine, and talk to him. That worked but only while I was doing it. Then he tells me - he was drinking the last ten years, not clean- and oh yes, he regretted it pretty badly right then. Hmm. So I'm thinking, well he didn't need to be off tranxene. And the ativan is q6 hours, this is not going to work. To top it off we had short staffing; I had 4 patients, I'm charge, my other nurse has 5 and we've told 'em to hold admissions off till end of shift if possible! Which, they kindly did- we got one at 0630.

I call the doc, fortunately it's one whom I know has some sense and he restarts the tranxene, ativan is changed to 1-2 mg IV q 4 hours. Tranxene calms him down till midnight, when I promptly gave 2 mg IV ativan and some ice cream. More handholding, some talking, I have a soft spot for the completely helpless I guess, even if he got himself in this pickle. Charting? What's that? Chart checks? Ha! Fortunately he slept till 3:30 am so the paperwork got sorta messed with.

I didn't get the 4 am ativan to him on time because I got a post procedure out of bed, that takes 20 minutes and I change the bed linens when I do that. (18 hours in bed makes one funky bed, not to mention the patient) Then one other patient is too somnolent and she had outrageous insulin orders (110 units of novolog at night) so a glucose check is less than 50. Great. I made her drink juice and left her nibbling a cracker. Gave my IV ativan to mister shakey, who's running a 102 temp now and begging for blankets, which are all on the floor. Straighten him out, tuck him in, etc. Lab confirms my glucose is 55 on the diabetic. More juice! Wake her up to finish crackers!

Now my alcoholic wants to know why he's wet. Hmm. Well, bless my soul, it's because he's pulled his IV out and has had it running into his bed. Was this before or after I gave ativan? I have absolutely no idea, but I hope it was after. Got linens, IV tray and go to work. Two sticks later I got an IV in, fluids restarted, but he is acting more and more hard to rouse while I clean him up. Too weak to sit up, I have to redress him like a ragdoll. Not shaking any more though, so I tuck him in and then my nurse yells from across the hall, do I want a recheck on his lab work, because his hemoglobin has dropped to 7 from a 9? Two grams? I yell yes please! and my stomach begins doing flips. From five thirty till 7:30 am, that patient did NOT MOVE a muscle. Took 20 minutes or so to get the absolute bottom line necessary paperwork done for next shift, taped report, then got calls from lab. Hemoglobin is really that low, potassium is 2.9! Tele shows HR of 50 but he still has p waves so at least I have a little minute to call the doctor. Then I gotta answer to pharmacy as to my nearly illegible and almost incoherent order that I scribbled down for the K-riders and adding K to the NS that's running.

You know what my silly pharmacist asks? If I have K in a vial I can just add? I'm like, uhh NO. That's called a lethal injection.... and doc wants 10 meq, not 20 in the bag so I can't use floor stock of that either. Please, please just quit asking stupid questions and send me the fluids! Which he did. Dayshift charge nurse came in and made my diabetic patient eat more crackers and juice before going to report, and my other nurse (who worked her tootie off with 5 grumpy patients and 4 cardiac drips btw) took vitals on the admission, while I hung the fluids on my alcoholic. Who's, in my opinion, unresponsive.

Anyhow. I left an hour late, barely did computer charting, the diabetic came up to 82 by then and the doc was aware that the insulin orders were - as I told him- ridiculous. Oh yes, and the glucometer refused to work around 6 am. I really wanted to do bad things to it. The nurse I passed off my alcoholic to, had talked the oncoming hospitalist into coming up to see the patient, as his magnesium level was also low, and ammonia level was not abnormal. I still feel bad since I really thought he would go downhill 10 hours before he did, and I dunno what went on with him when he did. Can't tell if he got too much fluid and diluted his hemoglobin and electrolytes... he didn't eat much at all for several days, got PO vitamins but no TPN. I only saw him have orange juice and one little cup of ice cream. I can't shake the feeling that I missed something big, and am just lucky by the skin of my teeth that he didn't arrest with a potassium that low.

I'm also grateful that the oncoming shift was nothing but helpful... I've never passed off to a shift that was that understanding before- one nurse even brought in fresh baked goodies and I went home with a slice for my breakfast.

/vent mode off now... any insights into what I missed would help, I guess... for the next time I see something like that.

[clee1]

God bless you, Nurse.

Sounds like you worked your tookis off.

[zacarias, ASN, RN]

Wow, you were so busy with that ETOH patient. You did well. I have one question though. Do you have an ETOH pathway at your hospital? It doesn't sound like he was getting enough meds at first.

[Indy, LPN, LVN]

I agree about his meds, I don't think we have a pathway. The fella got a couple units of blood the dayshift after I left him, got wild again, then filled his lungs up with fluid that night and went to ICU finally. He's alive and on a vent; that's all I know at this point.

We have a good hospitalist service in most ways but they do seem to differ from each other in how they treat withdrawal. One guy I had was on a bowel prep while his withdrawal started and boy howdy, was he miserable. Pulled his IV's out, shat all over the place, and ate his pepper packages. And murphy's law dictates that you can NOT have a patient in withdrawal without some other kooky or emergent thing happening at the same time! That night it was a code, two bleeders from IV sites, and one ole dude on fall precautions who slept standing up.