Substance Abuse, Gastrointestinal, Behavioral

Alcohol withdrawal and delirium tremens, GI bleeding, and de-escalating and sedating the violent patient.

Substance Abuse, Gastrointestinal, Behavioral

Alcohol Withdrawal and Delirium Tremens

• Alcohol withdrawal occurs when a patient who regularly consumes large amounts of alcohol suddenly stops or reduces the amount of alcohol intake. Alcohol is a downer, it suppresses. To compensate for the suppression, the body becomes more excitable to counterbalance the suppressive effects of alcohol. When the alcohol intake suddenly stops, the body's compensatory mechanisms of increasing excitability are still present, and without alcohol to balance it out, the body becomes increasingly excitable. o As a result, if every body system is ramped up, patients present with anxiety, irritability, combativeness, diaphoresis, nausea, tachycardia, hypertensive, hyperthermia, tremors, seizures and even hallucinations. o It can ultimately be deadly as a result of dehydration, electrolyte abnormalities, metabolic acidosis, arrhythmias, seizures and even as a result of being a danger to themselves. • Specifics of the workup o Point of care glucose: common in alcohol withdrawal as these patients typically do not eat appropriately o Complete Metabolic Panel: Assess for electrolyte abnormalities. Assess renal function and liver function, which can be damaged from chronic alcohol use. The kidneys can be damaged from acute dehydration o CBC: Ensure issues like infections or low hgb are not missed. o Urine Toxicology: To assess for drug use which may be the cause of the current symptoms o Serum Alcohol Level o Coagulation study: As the liver plays an important role in clotting, it may be ordered to assess whether there are any issues or when suspected if hbg is low o ECG: Assess for arrhythmias which can be predisposed by electrolyte issues or from the heart being overly excitable o CT Head: Rule out other causes for confusion and hallucinations o CIWA Assessment: Helps provide a numerical value for the severity of symptoms associated with withdrawal. The higher, the worse symptoms are and the more aggressive management should be. ▪ Includes Nausea and vomiting, tremors, sweating, anxiety, agitation, hallucinations, headaches, and mentation/confusion. • Treatment o Quiet environment and sitter ▪ A sitter is often required to help prevent the patient from accidentally harming themselves as a result of their confusion and hallucinations o IV fluids ▪ To help correct dehydration as a result of vomiting, diaphoresis and poor oral fluid intake by patient o Dextrose ▪ Will be as an infusion with IV fluids as needed o Thiamine, Folic Acid and Vitamins ▪ Help prevent Wernicke's encephalopathy and help correct deficiencies present from chronic alcohol use o Electrolyte Replacement ▪ Fix electrolyte abnormalities as indicated o Benzodiazepines ▪ Common 1st line medications. They help alleviate withdrawal symptoms as they calm the body and nervous system, taking the place of alcohol. They work on GABA, an inhibitory neurotransmitter, just as alcohol does. ▪ In mild to moderate cases, patients will get a scheduled dose of Lorazepam given, typically PO. Depending on the CIWA score, they may get an additional dose of Lorazepam to help alleviate symptoms. If the CIWA score continues to remain high and or is trending up, and the patient is needing more IV Pushes of Lorazepam, the patient will be upgraded to ICU status and a Lorazepam drip may be ordered. • If on a Lorazepam drip, close monitoring is essential to monitor for respiratory depression and improvement of symptoms. Place the patient on end tidal CO2. o Phenobarbital ▪ When patients are not responding to Lorazepam, phenobarbital should be added to help increase effects on GABA. Hence, further helping reduce the overexcitability present in the body. ▪ It will be administered IV, typically with an infusion of 10-15 minutes, depending on the dosing. I typically will place the phenobarbital into a 50ml or 100ml NS bag, and infuse it over 10-15 minutes. Check with your facility for administration, however, typically you do not want to infuse faster than 60mg/min. o Additional Medications that may be used ▪ Dexmedetomidine • Adjunct therapy used in combination with Lorazepam. It is typically used for its sedative effects, which is essential when patients are very aggressive, combative and confused. • Close monitoring is ideal as it can cause bradycardia. While using, I've had patients go really brady before, so please keep bradycardia at the back of your mind when starting Precedex (Dexmedetomidine). ▪ Propranolol • Used to help with autonomic hyperactivity ( tachycardia and hypertension). Adjunct therapy should never replace appropriate dosing of Benzos and phenobarbital. ▪ Antipsychotics • Typically not used as they lower the seizure threshold and have effects on QT intervals, predisposing patients to arrhythmias. However, they may be ordered for severe agitation and confusion. • Nursing o CIWA: Learn to calculate and what it entails o Check a POC Glucose o Multiple IV's and ideally in the forearm (so patient does not have to be reminded to straightened their arm). You will be giving fluids, replacing electrolytes, giving benzos and patients may pull them out due to confusion. ▪ Cover IV's to help prevent patient removing o Communication with the managing provider/team is crucial as these patients when critical will need many doses of benzos and or additional medications. So promptly communicate when the CIWA is worsening or if the patient is becoming more confused and a danger to themselves and others or if vital signs are changing o Seizure padding should be placed o If on Lorazepam drip, place the patient on end tidal CO2 to help closely monitor respiratory status.

Gastrointestinal Bleeding

• GI bleeds refer to bleeding anywhere along the GI tract from mouth to anus. Its typically separated as upper GI bleeding (esophagus, stomach, duodenum) and Lower GI bleeding(rest of small intestine, colon, rectum and anus). Can be deadly when there are great amounts of blood lost, especially when it occurs rapidly. o If the bleeding is severe, signs of hemorrhagic shock may be present such as paleness, hypotension, tachycardia, aloc, or dizziness. As well as abdominal pain/discomfort and nausea. ▪ Upper GI Bleed: Bright red emesis or coffee ground emesis, Black Stools ▪ Lower GI Bleed: Bright red stool o Causes can include peptic ulcers, esophageal varices, gastritis, cancer, diverticulosis and hemorrhoids. ▪ Chronic alcohol use is associated with gastritis and liver issues, which make patients more prone to GI bleeding ▪ Chronic NSAID use also places patient at an increased risk of GI bleeding • Specifics of the workup o Labs ▪ CBC: Assess hgb, hematocrit and platelets ▪ BMP: Assess electrolytes and kidney function to determine if injury is occuring to other organ systems from the GI bleeding (lack of perfusion) • Liver function tests: to assess the Liver as it plays a role in clotting ▪ Coagulation: Assess Pt, ptt, INR ▪ Type and Crossmatch: To give the patient blood products if needed (If your provider forgets to order, remind them) ▪ Lactate: helps assess perfusion status and we can trend to verify treatments are having a positive effect o Guaiac Testing: Directly assess for blood in stool o CT Angiography: Help determine where in the GI tract bleeding is occurring o Esophagogastroduodenoscopy (EGD): Through a long scope/catheter that has a camera attached, the GI provider can directly visualize the Upper GI tract and if source of bleeding is located, can treat with banding, clipping or cauterization • Treatment: How aggressive the treatment will depend on whether the patient is stable or unstable o Blood Products including PRB's, FFP and Platelets ▪ If bleeding is not severe, a fluid bolus can be given o If severe enough, A Massive Transfusion with high numbers of blood products through a rapid transfuser (can deliver entire units of blood within minutes) o Medications ▪ Proton Pump Inhibitor: helps decrease acid reduction to promote healing ▪ Octreotide: Used primarily when variceal bleeding is suspected as it helps reduce portal hypertension, which helps decrease the amount of bleeding. This effect is also useful post treatment/fixing to help prevent rebleeding. You will typically give a bolus/push then start an infusion at a set rate. ▪ Antibiotics: Will be given to prevent infections such as SPB (Spontaneous Bacterial Peritonitis) o Blakemore or Minnesota Tube: Places pressure on the bleeding site (especially esophageal varices). This is a stabilizing measure, giving the team time to initiate other interventions. o EGD: Banding, Clipping o Embolization by Interventional Radiology: Essentially, cutting blood supply to bleeding area o Surgical Repair • Nursing o Place additional priority on unstable GI bleeds as they can rapidly deteriorate and Code o Know how to use your organizations rapid blood transfusion and if Massive Transfusion Protocol is activated, discuss with your provider unless protocol is clearly detailed, how many Units of RBCs vs platelets vs FFP (what ratio do they want) o Multiple IV's as different medications and interventions will be implemented. If the patient requires a massive transfusion, a large bore IV is ideal for rapid administration of blood

Aggressive Violent Behavior

• Your safety is a priority. You won't be able to help the patient in front of you or any patient, if you become seriously hurt. • The patient's safety is also an important priority. This may include not allowing them to further hurt themselves, assisting them in regaining control and ensuring we assess for and treat any medical issue found such as Intoxication, Seizure Postictal, Hepatic Encephalopathy, Head Injuries, Electrolyte issues and so forth. There can be countless causes for why the patient lost their sense of control. • Patients who are irritated or upset but are still in their right mind will respond to good skills in de-escalation. The ER is busy, wait times can be long, they may be in pain, may be anxious, the average person will get irritated. Do not take it personal. o Always maintain a safe distance ( Any patient is capable of violence ) o Remain calm and composed. I know this can be difficult, we are human. The ED may be short staffed, you may not have even gotten a chance to use the restroom yet or even eat a snack. But if we respond with frustration, it usually just escalates the situation. o Show Empathy and Listen Actively: Demonstrate that you are genuinely listening by repeating back what the patient has said. My go to is, "I hear you." Building rapport is key, so you could also say something like, "That sounds very frustrating. Let's figure this out together. Here's what I can do right now." o Focus on How You Can Help and Offer Simple Choices: While you may not have control over certain things like wait times, you can provide assistance in other ways. For example, you could offer an ice pack, message the provider on their behalf, check where they are in the process, find them a place to sit, or even offer a meal. Direct towards the things you do have control over. But if we respond with frustration, it usually just escalates the situation. o Set Clear Boundaries and Don't Hesitate to Call Security: Never allow the patient to block your exit. It's important to remember that any patient is capable of violence, so always stay aware of your surroundings. If a patient is yelling or using abusive language, calmly say, "I understand how upsetting this can be. I'm trying to help you, so please lower your voice so we can talk, and I can understand the situation." If they continue, while staying mindful of your environment, calmly but firmly ask them again to lower their voice. Let them know that if they are unable to do so, security will be called. Despite common culture as just part of the job, no one should ever be aggressive with you. Don't put up with it. • Patients who are not in control of themselves may most likely not respond to de-escalation techniques. If they are aggressive, not receptive to de-escalation techniques and showing signs of escalation like pacing back and forth with fists clenched and actively stating that they are going to hurt you, you MUST call security for back up. Let the provider know after security. They may try different de-escalation techniques or just the fact that there is more personnel may persuade the patient to sit down and listen and perhaps choose and agree to medications. o The situation may further escalate and turn into a take down where the patient is four point restrained and given antipsychotics/sedatives. When restraining, to help avoid injury to staff and patient, you need a minimum of 6 people. One person at each limb, one person to help ensure the patient is not biting or spitting and one person actively placing the restraints. It should be one arm up and one arm down and legs spread apart. o It is important these patients also receive antipsychotics and sedative medications to help them relax because if they don't, they will continue to fight against the restraints and further injure themselves. • Medications ordered to help calm/sedate these patients will vary from provider to provider, but they should keep in mind the cause of the agitation. Antipsychotics should be administered when schizophrenia, bipolar or delirium are suspected as the cause of the agitation, while benzodiazepines can be used when the agitation is as a result of alcohol withdrawal and intoxication with uppers (meth, PCP etc). o You'll find that in violent patients where rapid sedation is needed, both types of medications are ordered. You'll come across the phrase B52. Stands for Benadryl 50mg, Haldol 5mg and Lorazepam 2mg. (There are providers that may order Olanzapine 5-10mg instead of the haldol). In acute agitation, these medications are going to be given Intramuscularly (IM). It is very difficult to place an IV on a patient that is combative and that is the perfect recipe for a needle stick injury. o Benadryl: Although an antihistamine, it does have sedative effects and it helps prevent EPS symptoms from administering Haldol (or Olanzapine) o Haldol: A first generation antipsychotic commonly used for agitation. A key potential side effect of haldol is that it can cause QT Prolongation and in susceptible patients that can lead to Torsades De Pointes. o Lorazepam: A benzodiazepine, a sedative. One of its many uses includes administration for acute agitation in combination with other medications like Haldol. A key side effect is respiratory depression. o KEY NURSING POINT: After giving medications, you must be very vigilant and closely monitor the patient. When these drugs are combined together, their potential for adverse effects intensify. These adverse effects include respiratory depression and ECG changes. As soon as you are able to safely do so, place the patient on the monitor spo2, ecg, BP, RR, Capno. If your combative verbal patient suddenly goes quiet, please be alarmed and go to assess and place on the monitor. This is very important when you've had to redose patients multiple times, all the medications can suddenly take effect together and cause respiratory depression. ▪ After the patient is sedated, do not lag in performing or obtaining the ordered tests. Do them while the patient is sedated. These include the ECG, going to CT, drawing labs, giving additional medications and so forth. ▪ With that in mind, if a patient is not cooperative and may become violent, do not attempt any intervention that may lead to personal injury such as lab draw. Discuss with the provider the potential for injury and if need be, state that you feel unsafe performing a task on a patient who may move and or cause injury to you. If the patient is borderline, discuss the use of PO medications while offering the patient food. When they take effect and the patient is more cooperative, then you can safely perform interventions. • Other Medications include Olanzapine, Ziprasidone, Droperidol, Versed and Ketamine. Again, unless your facility has specific guidelines or protocols for acute agitation, the medications of choice for acute violent behavior will be provider choice. Your job is to ensure your safety and the patients safety. o Olanzapine: A second generation antipsychotic that can be used for acute agitation. Common first dose is 5-10 mg IM. Side effects include hypotension, QT prolongation and oversedation (closely monitor when combining with other medications). o Ziprasidone: A second generation antipsychotic that can be used for acute agitation. Common first dose is 10-20mg. The Key Issue with Ziprasidone is its potential for QT Prolongation and ultimate torsades de pointes. As with haldol, careful use of it in patients with ecg/cardiac issues. o Droperidol: An antipsychotic that can be used for acute agitation. Common dose is 5-10mg IM. Key side effect is QT prolongation and as a result deadly rhythms. o Midazolam: A benzodiazepine with strong sedative properties that can be used for acute violent behavior. Dosing is 2.5-5mg IM. Key side effects include respiratory depression, oversedation and hypotension. o Ketamine: A dissociative anesthetic with potent sedative properties. I've typically seen ketamine ordered for the very severe violent patients who've typically come back positive with multiple substances on the tox screen like PCP and meth. Dosing Intramuscularly may seem like a lot, it is 4-5mg/kg IM(Intramuscular). Key side effects include emergence reactions (confusion when waking up), increase in HR and BP, and in rare occasions laryngospasm (may have to intubate). o Nursing Key Point: Closely monitor your patients after administering any of these medications. Watch out for oversedation, respiratory depression, hypotension and QT prolongation. Place on the cardiac monitor with continuous SPO2, BP, RR, HR, ECG and even end tidal CO2. In emergency situations with acute agitation, these medications are going to be given IM. • Charting Tips: Ensure your charting supports the use of restraints and sedative medications. Clearly state why these interventions were performed including the patients behavior, abusive language, physical attacks that were made by the patient and so forth. o Include the least restrictive methods that were used first including therapeutic communication, de-escalation techniques, offering PO medications, offering food and so forth. Include how the patient was at risk of hurting others and hurting themselves. o When charting about restraints ensure to include the type, where they were placed, assessments of the placement sites, and constant evaluation for the need of restraints. Plus how you assessed for injury, pain, need for restroom use, water, food etc. o Chart when and how the provider was made aware and the orders given o Ensure your documentation is in line with the policies of your facility

Updated 12 Sep 2026