What role does N-methyl-D-asparate (NMDA) have with alcohol withdraw and long term alcohol use?
NMDA receptors are upregulated and the concentration of neurotransmitter glutamate increases.
When alcohol consumption stops GABA is not inhibited and there is an increase in NMDA –> CNS hyperstimulation
What role does Gamma-aminobutyric acid (GABA) have with alcohol withdraw and long term alcohol use?
Long term alcohol use –> down regulation in GABA and a reduces the sensitivity to GABA receptors.
When alcohol consumption stops GABA is not inhibited and there is an increase in NMDA –> CNS hyperstimulation
- Initial: withdraw symptoms: When and what? (7)
6-8 hours after last drink
- Tachycardia
- HTN
- Increase body temperature
- Tremulousness
- Anxiety
- N/V
- Palpitations
- Alcohol hallucinations: when and what?
12-24 hours after last drink
- Tactile hallucinations
- Auditory hallucinations
- Tremor and other withdraw s/s
- Normal sensorium
- Withdraw seizure: when and what?
- Generalized tonic clonic (isolated, short duration and short post-octal period)
12-48 hours after last drink
What does delirium tremens occur? How long does it last?
3 days post appearance of s/s of of alcohol withdrawal
Lasts 1-8 days
- Delirium Tremens (6)
- Rapid onset
- Fluctuating disturbance of attention and cognition/LOC changes
- Alcohol withdrawal s/s
- hallucinations
- Confusion
- HTN
What does the diagnosis of delirium tremens require?
autonomic instability
If delirium tremens is poorly managed, what are the s/s?
- Cardiovascular and respiratory collapse
- Arrhythmia
- Dehydration
- Electrolyte imbalances
- Multiorgan dysfunction
What is the mortality of delirium tremens if untreated?
5-15%
What is a first line medication for DT and alcohol withdrawal?
Benzodiazepine
Stops the progression to DT
How do benzos work for alcohol withdrawal?
Control the s/s by interacting with GABA in the brain –> increase in GABA transmission –> decreased CNS excitability, decreased risk for seizures and prevents progression to DT
What are the nursing considerations regarding benzos?
- Poor liver function can cause accumulation of a toxic metabolite
- Kidney disease prolongs the action of Diazepam
- Chlordiazepoxide and Diazepam are hard on patients with liver dysfunction so the dose may need to be adjusted
- Alprazolam or lorazepam may be better for patients with liver dysfunction
What route should benzodiazepines be given in alcohol withdrawal?
Via IV because there is a rapid onset and more predictable bioavailability
Which medications can be used other than benzos? (4)
- Phenobarbital
- Propofol
- Ketamine
- Dexmedetomidine
What medications should be avoided in patients with alcohol withdrawal?
- Antipsych
- Anticonvulsants
- Alpha-agonist (baclofen)
- Beta blockers
What is the first thing you should do for someone in alcohol withdrawal?
Resuscitation and stabilization and evaluate for any life threatening conditions
What other things should be included in a plan of care for alcohol withdrawal patients?
- Thiamine (lab test d/t nutrient deficiency)
- Replacing electrolytes: typically hypokalemic so treat with K+
- Seizure precautions
- Get a good history
- CIWA
- Intubation and MV may be necessary for patient with DT
How often is a CIWA preformed?
every 30-60 minutes
A score less than 8 on CIWA means
mild withdrawal
A score of 8-15 on CIWA means
moderate withdrawal
A score over 20 on CIWA means
severe withdrawal
A score over ___ should get medication therapy
8
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Coagulation Disorders86
-
GI disorders73
-
Acute Neuro Injuries114
-
Spinal Injuries98
-
EKG129
-
Transplant63
-
AKI70
-
Dialysis53
-
ABG41
-
Mechanical Ventilation106
-
ARDS54
-
Cardiac - inflammation61
-
Cardiac valvular diseases77
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Diabetes, DKA, HHS, Hypoglycemia104
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Endocrine22
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CIWA23
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Oncology emergencies152
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Trauma116
-
Shock125
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Burn77
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Care of burn patient76
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CEC/SIM12
