Psych/Addictions: Withdrawal vs EPS

[electricblack]

So it happens that I work nights and they put me in Charge even though I still lack the experience and traning of being a Charge Nurse. One of the staff working with me was also a new RN and her pt has been experiencing new symptoms of leg spasms. The charge nurse earlier on thought it might be EPS from her new medication 60mg Cipralex OD because she just started that day as well. Then she started feeling restless and by night time she is moving around unable to sleep. The charge nurse for that evening then assumed shes going through withdrawals. The pt also needed a walker because shes a falls risk but no walker was located as per my request earlier on in the day and she needed to be assessed by OT still (I wouldve grabbed any walker at that point just to prevent any possible falls).

That night the medical doctor assessed her and decided she's low on phosphorus but would not prescribe anything since he believes shes withdrawing from her Percocets she used to take three or more a day and tried to OD on it prior to admission.

At the end of the night we manage to get orders for Ativan 1mg q2h and Clonidine 0.1mg q6h. Two 1mg doses were given in four hours time and she remains drowsy but unresolved symptoms... clonidine was provided and vitals were done q1h and she was placed on q15 watch because she continues to get up of bed even though shes more a falls risk now than ever.. . her symptoms were not resolving at all. On call psych was on the phone with us on and off and neither her nor the med doctor on call would prescribe cogentin unless they have assessed the pt one on one... in fear of side effects like malignant hyperthermia.

Blood work was done cbc creat lytes to avoid having kidney problems from her spasms... (0 seizure, afebrile, slightly hypertensive)....pt then had an unwitnessed fall as she tried to walk out her room. Mental status remains intact except that she is slightly sedated from the ativan and remains restless. We did an incident report, checked vitals and head to toe while she remains seated... no physical damage was seen... and she said she slid down rather than fall flat but had hit her head slightly on a chair... i had to request for a ct just to be precautious but she states shes in no pain and was just shakin up.

All of these happened at 4am until 7am and all along she states that her spasms had progressed to her arms... yet the doctors did not deem it emergent enough to see her. We kept a very close eye on her and maintained q15 as she slept vitals were q1h and bp was slowly going down to her normal as she is now settled in bed... Glasgow coma was done q15 at first hour and we monitored her and documented everything.

-----Sorry for the long background but thats what happened. I am not sure exactly where to go from here. I am still not well versed with the difference between EPS vs Withdrawal(Percocet) and am unsure if I handled the situation appropriately. Either way it did leave me shaken up and hope to be prepared for it next time.

Some feedback would be appreciated.

[Meriwhen, ASN, BSN, MSN, RN]

How much Percocet had she been taking and how long had she been taking it? If we're talking only a recent Percocet use, it's likely NOT opiate withdrawal.

Also, what other symptoms were going on that lead you/them to believe it's an opiate withdrawal? Opiate withdrawals are one of the more hellacious detoxes--it wouldn't manifest only as leg spasms. Your patient would pretty much appear to have the flu: generalized body aches and spasms, N/V/D, stomach cramping...along with rhinitis, watery eyes, lethargy, and dilated pupils.

Here is a link to the Clinical Opiate Withdrawal Scale, a.k.a. COWS:

http://www.emcdda.europa.eu/attachements.cfm/att_35646_EN_COWS.pdf

This is used to help judge the severity of a patient's opiate withdrawl. Basically, this is what you should expect to see.

[electricblack]

She has been on Percs for a good few years. I honestly am unsure if it was withdrawals but some senior nurses said it might be due to her history and presentation. She was afebrile and she has been on our unit for two days so far. Rhinitis was not present, pupils are responsive and she did have some nausea 0vomiting., as for her energy levels there was no decrease or increase aside from the fact that she became sedated after ativan was provided. She was assessed by an MD at midnite and states it was possible withdrawal symptoms and to contact the on call Psych. The on call Psych was provided as much details of her symptoms and she assumed the same thing. Her status did not really deteriorate, it was more that her symptoms did not improve after medications. ABC were not compromised aside from the slight elevation of bp possibly due to her moving around which did decrease after she settled. I was more worried for diagnosis that are possibly overlooked.

[electricblack]

COW Score = 9 (mild)

[Whispera, MSN, RN]

Cipralex isn't likely to cause EPS. Medications that lower dopamine cause EPS and Cipralex doesn't do that, unless it does it and we're not aware of it yet.

Cipralex can cause restlessness as a side effect, and too-big a dose can cause serotonin syndrome which can include extreme restlessness.

[electricblack]

great feedbacks... thank you guys.