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Fast treatment of alcohol withdrawal can save lives
Imagine a middle-aged woman who seems a bit nervous and whose hands are shaking slightly. Would you suspect alcohol withdrawal syndrome in this patient? If not detected quickly, the patient’s symptoms could quickly become life-threatening.
Alcohol withdrawal has the potential of causing severe morbidity and mortality, warns Victoria Leavitt, RN, regional nurse educator for emergency services for Franciscan Health System, a three-hospital system in Washington’s Puget Sound area.
Subtle or early symptoms may escape detection, which causes patients to be overlooked in a busy ED, she says. "The fine sheen of perspiration, hand tremor, and general jitteriness may be lost in the crush of patients at triage," she says. "Most EDs are over-crowded and understaffed. It is not surprising that some people will fall in the cracks."
The longer you wait to give medication, the more serious the signs and symptoms become, explains Suzanne White, MD, FACEP, FACMT, associate professor of emergency medicine at Wayne State University School of Medicine in Detroit and an ED physician and medical toxicologist at Detroit Medical Center. "If patients are not treated quickly, it may progress to full-blown delirium tremens, which quickly can cause death," she says.
If the patient is exhibiting confusion, seizures, fever, tachycardia, tachypnea, hypertension, diaphoresis, or altered mental status, then there is a chance that the patient may die — even with treatment, says Leavitt. If you overlook a patient and an adverse outcome results, there is also the possibility of a malpractice lawsuit, she adds. "Left untreated, alcohol withdrawal can be life-threatening," says Leavitt, who adds that delirium tremens carries a death rate of up to 35% if left untreated.1
"If [alcohol withdrawal] goes unrecognized by the nurse, it is just as if she did not recognize a potential myocardial infarction and would constitute a missed’ triage," she says.
To dramatically improve care of alcohol withdrawal patients, do the following:
If a patient fits your expectation of a person likely to drink excessively — such as poor, male, and unemployed — he may be more quickly diagnosed than a woman with a fractured hip with no immediately visible symptoms, says Leavitt.
Remember that alcoholism cuts across gender, social, and age lines, says Leavitt. "I have taken care of 25-year-old male patients who are having withdrawal symptoms as well as women in their 60s," she says.
Many conditions often seen in EDs look a lot like alcohol withdrawal, including drug overdoses, infection of the brain, hypoglycemia, or patients who are post-ictal, says White. "It’s a great masquerader," she says.
If you fail to recognize the emerging symptoms of alcohol withdrawal, the patient may be treated for the wrong condition, Leavitt warns. Look for the following signs and symptoms: abnormal vital signs, tachycardia, high blood pressure, elevated temperature, slightly enlarged pupils, and abnormal perspiration.
"These patients will look seem to have a lot of adrenaline in their system," says White. "One of the hallmarks is the tremor of the hand, eye, or tongue."
If the patient is in full-blown delirium tremens, expect to see an altered mental status, such as confusion or delirium. "The important thing is to catch them before they get to that point, when the patient comes in and reports feeling anxious," she says.
Alcohol and substance abuse screening should be a standard part of triage, says Leavitt. "Normalize the questions by being matter of fact," she recommends. "Avoid a show of surprise when someone tells you, for example, that they drink a pint of whiskey a day."
Whether screening occurs at triage or at the bedside, the goal is to diagnose the patient early, so medication can be given to prevent escalation of symptoms, says White.
If a patient gets admitted from the ED for an unrelated problem such as an accidental fall and their alcoholism is unknown, that patient may go into alcohol withdrawal on the inpatient floors, White says. "This is a very common scenario," she adds.
Early use of benzodiazepines is key, and you should treat in response to the patient’s symptoms, advises Leavitt. "If the patient is still tremulous after 50 mg diazepam, then they have not had enough diazepam," she says. "Patients should be as symptom-free as possible."
There is no ceiling on the amount of benzodiazepines that may be given in these circumstances, and alcohol withdrawal syndrome is not an "all-or-none" phenomenon, says Leavitt. Symptoms may range from mild jitteriness to delirium tremens, she says.
Use an objective scoring system to assess severity of withdrawal, as this system will allow you to titrate the therapy to the individual patient, says White. "We no longer recommend fixed doses, such as 5 mg diazepam every 10 minutes," she says. "That is no longer considered the best way to approach this problem."
White recommends using the Revised Clinical Institute Withdrawal Assessment for Alcohol scale, which monitors the level of agitation or anxiety, orientation status, and whether the patient is vomiting, perspiring, or having hallucinations. (See resources, below, to obtain scale.) "When used properly, this allows for less medication to be used in a shorter treatment period, with a better outcome," says White.
1. Accessed at http://www.emedicine.com/emerg/topic123.htm.
For more information on caring for patients with alcohol withdrawal syndrome, contact: