Microsoft powerpoint - hair of the dog for 2002 backup

• Copies of slides and modified CIWA (Clinical Institute Withdrawal Assessment) scale available at: • 1 in 13 Americans abuses alcohol• Alcohol is the 2nd leading cause of death • Economic losses from alcoholism exceed • Be Vewy, Vewy Careful• Trust No One• Assume Nothing• Follow all 5 vital signs serially• Treat withdrawal adequately• R/O infection and metabolic imbalance• Always consider CNS etiology correctional facilities is a problem of triaging a huge volume of patients to yield a low number of critical (but dangerous) cases • Critical to have a predefined process• Critical to have individualized therapy • Very aggressive medical treatment tied to • Reliable, reproducible, validated, and • Primarily intended for alcohol, but it • Serial scoring drives individualized • Temperature• Pulse• Respirations• Blood pressure• Nausea / vomiting• Tremor• Sweating • Hallucinations• Mental status• Agitation• Thought disturbances• Convulsions / seizures• Headache – Seen when cellular tolerance to ETOH – Often treated with another drink– 1-5% will progress to full DT’s • Detoxify patient over 3-5 days• Use benzodiazepines• Nutritionally fortify• MVI (for niacin)• Thiamine• Reassess regularly for progression to • Most alcoholics are dehydrated• Fluid of choice = D5NS at 200/hr with: – MVI (1-2 amps)– Folate (1-5 mg)– KCL (40 mEq)– MgSO4 (5 grams)– Thiamine (100 mg IV) • Alcoholics have NO glycogen stores• FEED THEM!!!• Alcoholics tend to become • Significant reduction of delirium (p=.04)• All equally efficacious; longer half-lives preferred for smoother withdrawal, less abuse potential • Titrate medications to symptoms• Generally give 5 days with taper• Do not undermedicate• Drug of choice is whatever you are • Bolus initially• Redose q 30 minutes until lightly sedated• Average loading dose = 600 mg • Do not use routinely• No role if no prior seizures• No role if alcoholic seizures have already • Conflicting data in drinker with previous phenytoin are drinkers with idiopathic epilepsy or previous history of CNS – Not recommended as monotherapy, can be • Neuroleptics (haldol, phenothiazines) – Increase incidence of seizures compared to – Less effective than benzodiazepines– Can be used to calm agitated patients in – 10% of patients with prior seizures will – Without treatment: 5-30%– With treatment: 1-6% • Seen in 25% of “professional” drinkers• Visual 5x more common than auditory• Treatment – More aggressive benzodiazepine use– Hydration– Possible IM Haldol • Usually 1-6 seizures• Usually tonic-clonic, rarely status• Majority occur within 48 hours• If patient medicated with benzodiazepine • 308 patients, 294 controls• 60% of seizures were random events• Frequency of seizures increased with – 3x normal if ½ pint per day– 8x normal if 1 pint / day– 20x normal if 1 quart / day • 2375 Patients• 1915 Mortality = 52%• 1935 Mortalty = 14% • No nurses • Dehydration • Physical restraints • Neuroleptics • Be vigilant for pneumonia, GI bleeds, sepsis, • Focal seizures• Febrile • Status epilepticus • Any of the above warrant workup in the • 5 Basic Causes of Altered Mental Status – Vital Sign abnormalities– Toxic/Metabolic causes– Structural Abnormalities– Infectious Etiologies– Psychiatric Illness • Pulse—Holiday heart• Resp—hypoventilation from CNS • Na (high or low)• K (high or low)• Glucose (high or low)• BUN/Cr (dehydration)• ABG’s (hypoxia, pneumonia)• ETOH level—if below 200, look for Calculated osmolarity = (2*Na) + (Glu/18 ) + OG = true osmolarity – calculated = 10-20 • Calculate in osmolar forces contributed • Each 3.2 mg% = 1 mosm• Profound acidosis, blindness, retinal • Do not induce vomiting• Charcoal is not effective• Patients must be transferred to ER • Each 6.2 mg% = 1 mosm• No odor• Profound acidosis• Early symptoms = euphoria, seizures• Cardiac symptoms = ST-T wave changes• Renal symptoms = crystalluria, failure• Transfer to ER • Each 6.0mg% contributes 1 mosm• Twice as drunk, twice as sick, twice as • Ketosis without acidosis• No anion gap• Symptoms mostly GI • CNS trauma• Alcoholics have occult injuries• Send out for CT, LP, EEG if necessary • CBC (sepsis, anemia)• U/A (ketones, oxalate crystals)• CXR (TB, Pneumonia, Lung abscess)• LP (meningitis) • Diagnosis of exclusion• 80% of seriously mentally ill have a co- – Ataxia– Ocular findings (nystagus, lateral rectus palsy)– Encephalopathy – Coma– Miosis– Hypothermia– Hypotension– Bradycardia • Due to thiamine deficiency• 20% mortality rate• Patients with AIDS, hyperalimentation, malnutrition, diabetes are at very high risk • Rhabdomyolysis• Myopathy• Hypothermia • Alcoholics are dangerous• Assume nothing• Educate your nurses and yourself• Develop a serial screening tool and • Treat aggressively• Don’t be afraid to refer them to ER (Clinical Institute Withdrawal Assessment) scale available at:

Source: http://wellcon.net/files/downloads/hairofthedoghandout_111219id10.pdf