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Angela Waring

Page
1


Forum Report

1.5
Neurological

-

Alcohol W
ithdrawal related
Delirium



Tremens (DT’s)


Angela Waring



A 56 yr old male was bought into the Emergency Department by ambulance on
Friday after
being found lying on the pavement with mild concussion
.
He had sustained a head injury to
his left forehead with a contusion and a black eye. The patient denied any other significant
medical history.
A
n ECG and a CT Brain scan showed no abnor
malities. The patient had a
BP
-
165/95, P
-
110 and T
-

37’2. His BGL was 7.3 mmols

and Alcohol Withdrawal Scale of 2
.
Blood pathology was attended
-

FBC, LFT’s, U&E’s. The Glasgow Coma Scale scored 15

and
pupi
ls equal and reacting to light. H
alf hourly ne
urological observations were commenced.
He lived alone and had no family or friends.
He was complaining of a headache
which was
unrelieved by analgesia.

It was decided to transfer him to the general ward for overnight
observations.



Two code blacks were called over the weekend on the client due to his agitated and
aggressive behaviour.
Both eyes were now blackened and the swelli
ng to the Left forehead
was still evident.

The damage caused by this

blunt
,

focal injur
y
,
also
peaks around
36 hours
(Craft, 2010).
An agen
cy nurse was assigned to ‘
special’ him

over the course of the weekend
.
H
e was reviewed and a

total of
55
mg of oral diazepam

had been administer
e
d

s
ince
admission.

Administration

did not always correspond with
document
ation of

the Alcohol
Withdrawal Scales

(at times

-

8’s and 9’s)

and was clearly
, upon review,

of insufficient
amounts at incorrect times.






Angela Waring

Page
2


Alcohol related Delirium Tremens

-

Cognition and perceptual disturbance


Craft, 2010 describes this
confusional
state as
a ‘disruption of a widely distributed neural
network involving the reticular activating system of the upper brainstem and its projections
into the thalamus, basal nuclei and cortex and limbic areas’.






Presentation



A
gitation,



R
estlessness,



G
ross
tremor,



D
isorientation,



Fluid and E
lectrolyte imbalance,



S
weating and

fevers,



V
isual hallucinations
(crawling bugs)



P
aranoia (Lopatko et al.,
2002
,

in

DHA,
2007)


Acco
mpanying clinical features
:

autonomic hyperactivity, such as hyperpyrexia,

tachy
-
cardi
a
, hypertension and diaphoresis (DHA, 2009).


Angela Waring

Page
3


Medical causal factors



Metabolic



Infectious




Toxins




Trauma
(DHA, 2009)





Q. What are the predisposing features of Alcohol related Delirium Tremens

(DT’s)

?



An accurate alcohol history was not gained
from the patient and he

had

minimised his
alcohol use. This
was complicated for staff by the

brain injury and
the
slight
ly worsening

contusion.
Apart from a ligh
t

headache, it

was not problematic

over the weekend. Delirium
Tremens

was diagnosed on Monday morning.

He later disclosed a history of 40 standard
drinks daily (with no alcohol free days) for the past 10 years and increasing isolation after a
divorce.

A
ppropriate treatment of haloperidol 5
-
10 mg x 2 and a total of 340mg of
oral Diazepam

was ordered
.
The a
dministering

aim of

Diazepam is to gain light sedation, (DHA, 2009)
whereby the patient is easily rousable.

This episode of the DT’s may have proved fatal.
Aminoff, Greenberg &Simon (2005)
also
suggest
that this is
especially
true
with

concomitant trauma’.

Mortality rates were once as
high as 15% prior to the improved

(1%)

treatment regimes of today (DHA, 2009).





Angela Waring

Page
4






Initial c
onservative treatment may have been triggered by:



The initial history




Traumatic Brain
Injury

and a

medical
knowledge that alcohol dependent persons
gain
cerebral atrophy

(as in the elderly population)

predispos
ing them to subdural
haematomas

(
Welch, 2011)



U
nclear
administration

instructions

for nurses

of diazepam on medication chart



The p
atient

s aggression
towards a junior nurse
and refusal to take Diazepam.

Patients with delirium may
require
a
mental health order as they are incapable of
rational decisions
and often want to discharge against medical advice when it would
prove
fatal to do so.
(Welch,2011
)



Inexperience
of

staff

When taking a patient
drug and alcohol history

the following should be considered: accurate
assessment, a prediction made about the severit
y of withdrawal (
which is
a self limiting
syndrome)
to be experienced,
appropriate

referral (if required) and

treatment

management
.

Alcohol is a depressant drug which

suppres
s
es the Central Nervous system. T
he opposite
effect, of high excitability
is recorded

with

moderate to severe

with
drawal (Craft,
2010).


Angela Waring

Page
5


American Psychiatric Association. 1994.

Diagnostic and Statistical Manual of
Mental Disorders

(4th ed.) (DSM
-
IV). Washington, D.C.: APA.








DSM
-
IV Criteria for Alcohol Dependence:

A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as
manifested by three or more of the following seven criteria, occurring at any time in the same
12
-
month p
eriod:

1.

Tolerance, as defined by either of the following:

o

A need for markedly increased amounts of alcohol to achieve intoxication or
desired effect.

o

Markedly diminished effect with continued use of the same amount of alcohol.

2.

Withdrawal, as defined by eith
er of the following:

o

The characteristic withdrawal syndrome for alcohol (refer to DSM
-
IV for further
details).

o

Alcohol is taken to relieve or avoid withdrawal symptoms.

3.

Alcohol is often taken in larger amounts or over a longer period than was intended.

4.

The
re is a persistent desire or there are unsuccessful efforts to cut down or control
alcohol use.

5.

A great

deal

of time is spent in activities necessary to obtain alcohol, use alcohol or
recover from its effects.

6.

Important social, occupational, or recreationa
l activities are given up or reduced because
of alcohol use.

7.

Alcohol use is continued despite knowledge of having a persistent or recurrent physical
or psychological problem that is likely to have been caused or exacerbated by the alcohol
(e.g., continued
drinking despite

recognition that an ulcer was made worse by
alcohol consumption).

Angela Waring

Page
6


Standard Drinks Guide




















Current recommendations
:
not more than 2
standard alcohol
drinks (male and female)
be consumed daily with at least two alcohol free days weekly
to prevent alcohol withdrawal
syndrome developing (DHA, 2009).



Angela Waring

Page
7


The patient required the

contusion
,

to the
left forehead,

excised and drained prior to
discharge and follow up counselling with Drug and Alcohol Service
.


Reccomendations



Awareness that alcohol withdrawal can be fatal with inadequate treatment



Review

all evidence
collectively

(history, pathology, presentation)
not just individual
pieces of
info
rmation and revisit history if necessary



Telephone referral to specialist Medical Officer on call after hours to clarify patient
management



Alcohol and Drug Liaison Nurses work after ho
urs, especially Friday and Sat
urday
nights (current

Monday to Friday 0900
-
1700hrs

operation
)




Clear guidelines from Medical Officers i.e.
Diazepam 10
-
20mg if AWS
> 5



Perform mini mental state neurological exam



CNC and CDN’
s responsibility
to
e
nsure accurat
e as
sessment and documentation

of
all

scale
s fore eg. AWS, GCS
,
used in
their clinical area
s
.



Awareness of
Risk factors:
poor nutrition, Isolation and age

of patient

(DHA, 2004)



Inform patients of Thiamine use for at least 6 months post discharge




This case study highlights the negative consequences of a simple
syndrome, Alcohol
Withdrawal, when

mismanaged. It should be noted this case study predates the Medical
Early Warning Scores introduced in the Australian
Capital Territory Health system.


Rema
ining up to date and having good communication skills, verbal and written, within the
multidisciplinary team is at the core of good health care delivery.







Angela Waring

Page
8



References


Australian

Government Department of Health and Ageing (2004).

Alcohol and Other Drugs:
A Handbook for Health Professionals.

Australian

Government Department of Health and Ageing (2009). Guidelines for the
Treatment of Alcohol Problems. NSW Health,

Aminoff, M. Greenberg, D &Simon, R. (2005). Clinical Ne
u
rology (6
th

e
d
.
). USA,
The Mc
Graw
Hill Companies.

Chulay, M. & Burns, S.

(2010). American Association of Critical Care Nurses. Essentials of
Critical Care Nursing (2
nd

ed.). USA, The McGraw Hill Companies.


Craft, J. & Gordon, C. Tiziani
,
A. (2010)
.

Understanding
Pathophysiology
. Chatswood,
N.S.W.: Elsevier Australia.


NSW Department of Health. (2007). NSW Drug and Alcohol Withdrawal Clinical Practice
Guidelines.


Welch, K. (2011). Neurological Complication of Alcohol and Misuse of Drugs: Acute
Presen
tations. Medscape, Practical Neurology, 11(4):206
-
219. Retrived 1/11/11