My relative is an alcoholic. If he were to go even a day without being able to drink, he would be in bad shape. His anxiety would increase and he’d be headed to a liquor store. If he went to the hospital, and did not tell his healthcare providers he was an alcoholic, he would begin to go through withdrawal within 24 to 72 hours after a hospital admission. This constitutes a medical emergency.

Many patients are not honest with their healthcare providers about how much they drink: “I drink socially.” “Social drinking” means different things to different people. I once taught a class on documentation to physicians. I asked them to write on a piece of paper their definition of social drinking. The variation in responses was amazing. One person wrote. “A social drinker is someone who drinks as much as I do.”

Patients may be injured while going through alcohol withdrawal. Delirium tremens is the most severe form of alcohol withdrawal and occurs 3-10 days after the last drink. It is fatal in 5-15% of the cases. Complications include vomiting and inhaling vomit into the lungs, cardiac arrhythmias, respiratory depression, respiratory arrest and need for intubation, and oversedation. Respiratory depression and oversedation are the most common causes of death.

Delirium tremens is associated with a period of heavy drinking, especially if the person was not eating a sufficient amount. But it may also occur when a person is a steady, daily drinker like my relative. Nurses may see patients showing these symptoms:

• Rapid heart rate
• Sweating
• Confusion
• Hallucinations
• Nausea
• Tremors
• Anxiety
• Agitation
• Seizures
• Fever
• High blood pressure

Physician Responsibilities for Alcohol Withdrawal

Malpractice suits may be filed against physicians because of these withdrawal-related issues:

• Failing to diagnose alcohol withdrawal
• Failing to order adequate doses of benzodiazepines (Valium and Librium are used); the doses may need to be quite large such as Libirum 50 mg. Alcohol withdrawal may be easily treated with benzodiazepines (Valium or Librium) on a proactive basis. The medication is given around the clock to ease the patient through the worst of the withdrawal process.
• Failing to rule out other causes for altered mental status in patients with suspected withdrawal from alcohol
• Assuming that a seizure is due to withdrawal without ruling out other causes of seizures
• Giving alcohol to an alcoholic in DTs; alcohol does not prevent seizures or DTs.
• Failing to admit a patient to the hospital who is in DTs

Nursing Responsibilities for Alcohol Withdrawal

Malpractice suits have been filed against nurses for the injuries that occur during DTs. Patients who survive the withdrawal process may be injured or injure others.

Nurses are responsible for routine questioning of all patients who are admitted to the hospital to ask them about their alcohol use. This is also a question covered by physicians during the history and physical. Nurses are expected maintain a quiet, calm environment, offering support and protecting the patient from falls and injuries. Patients going through DTs require one on one monitoring to prevent injury. They can be wildly out of control and impossible to reason with. Nurses are responsible for preventing aspiration by placing the patient on his left side or noting the need for intubation.

Once the acute phase is over, patients should be approached and offered counseling and support to help them deal with their disease and live without reliance on alcohol. Several centers specialize in helping a patient detoxify from alcohol.

Dealing with delirium tremens is high risk for both the patient and the healthcare provider.

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