Treating a patient with Symptoms of DT?

[NYMedic828]

So I had a patient at a rehab facility today who was being treated for very long term severe alcohol abuse (30 years)

Originally came in as a seizure but we walked in and the patient is in a chair, jerking in a seizure like fashion but concious, with random outbursts of words paired with a pretty pale look.

He was fully AO and able to hold a conversation with broken sentences. The story was that he has been sober 14 days, but was unable to acquire his prescribed medications due to some restriction to a particular pharmacy, which he could not make it to for one reason or another. He was txp two days prior for the same issue to which the hospital resolved via IM Ativan.

Vitals were
BP - UTO due to muscle activity
HR - 112
RR - 20
SPo2 - 95% room air
EKG - UTO as well.

We were only 10 min from the hospital.

My partner felt it would be a waste of time, so we didn't bother but would it have been worthwhile to call for a discretionary administration of say 5mg of versed IM just to reduce his condition vs sedating him with the usual 10 mg.

We carry versed and Valium here, and an IV was probably a long shot for Valium.

Mind you we do have standing orders to give either if seizure activity occurred, but he obviously wasn't seizing and we don't have standard orders for treating withdrawals regardless of how severe.

 

[Handsome Robb]

We are here to make the patient comfortable right? I would have told my partner to kick to is and called for orders but that just my opinion.

The guy is trying to get sober and having to constantly deal with DTs isn't going to help him stay on the right track.

Some may disagree with me.

 

[STXmedic]

Personally, I would have gone with 5-10 of Valium. No reason to not give him benzos, also reduces the likelihood of seizure or reoccurrence of seizure. And time to hospital =/= time to treatment (hate that excuse). I'd go Valium over versed just because of the longer duration of Valium.

Edit: In regards to orders. Do you know he didn't seize? Seizures due to alcohol withdrawal are common, so it's likely (even if you don't suspect it, you should still expect it.) What about sedation for anxiety/agitation? Sometimes you've got to make your protocols fit what you need.

 

[NYMedic828]

We are here to make the patient comfortable right? I would have told my partner to kick to is and called for orders but that just my opinion.

The guy is trying to get sober and having to constantly deal with DTs isn't going to help him stay on the right track.

Some may disagree with me.

That was my thinking...


As far as valium, we didn't have an IV and without forcefully holding him down to do it, it was not gonna happen. Id rather go with versed IM and let that stop his condition so an IV could be established for later use.

Protocols wise, we do not have any standing order for anxiety/agitation I would have to call for a discretionary decision and consult just the same.

He didn't seize he was reported in an conscious state the entire time by staff at the facility.

 

[STXmedic]

As far as valium, we didn't have an IV and without forcefully holding him down to do it, it was not gonna happen. Id rather go with versed IM and let that stop his condition so an IV could be established for later use.

Can you not give Valium IM?

 

[medicsb]

Could have been a partial/focal seizure. You don't need to have a loss of consciousness to have a seizure. I generally recommend that if one is unsure about treatment, it is best to contact medical command. It's just a couple of minutes of you're time.

 

[Aidey]

It wouldn't hurt to call, but I know if I called for orders on that patient here they would have likely been denied due to the transport time and because of the relative lack of severity of his symptoms.

I've given IM ativan to one DT patient, and I did not call for orders. I gave it under out generic "too agitated to perform necessary medical exam" protocol. She was in very bad shape between the DTs and liver damage. She was the color of a banana, her pulse was in the 180s, and she was very dehydrated (tenting, skin dry and flaking) and she was seeing pink bunny rabbits running around and kept trying to pet them. At least I think the bunny rabbits were pink, it was hard to follow her train of thought.

 

[46Young]

That was my thinking...


As far as valium, we didn't have an IV and without forcefully holding him down to do it, it was not gonna happen. Id rather go with versed IM and let that stop his condition so an IV could be established for later use.

Protocols wise, we do not have any standing order for anxiety/agitation I would have to call for a discretionary decision and consult just the same.

He didn't seize he was reported in an conscious state the entire time by staff at the facility.

I agree. One of the most meaningful and important ways we can help a patient in EMS is to alleviate pain and suffering. It's barbaric to say the least when you willingly withhold pain management and comfort measures.

I would have gone with Versed IM as well through the doc-in-the-box. In my system, we have IN Versed, Fentanyl, and Narcan. With the atomizer, it's easier than IM, painless, and has a quicker onset of action. Has there been any proposals to authorize IN admin in the NYC 911 system?

 

[NYMedic828]

Can you not give Valium IM?

Can not give morphine fentanyl or Valium IM on standing orders here.

Versed is far better absorbed IM than Valium anyway... (to my understanding)


While I can't officially diagnose anything the likelihood of a focal or partial seizure with full body convulsions and patients given history is pretty slim to none.

 

[STXmedic]

Can not give morphine fentanyl or Valium IM on standing orders here.

Versed is far better absorbed IM than Valium anyway... (to my understanding)


While I can't officially diagnose anything the likelihood of a focal or partial seizure with full body convulsions and patients given history is pretty slim to none.

Better absorbed, yes. I don't know about it being "far better" though. My biggest thing with Valium would the time to onset.

IN versed is always a great option too. I tend to prefer IN versed for a quick knockdown over IM of either. But he's also not combative from the sound of it, so I'd be looking for longer lasting over quicker acting.


History of alcohol withdrawal doesn't scream possibility of seizure to you?

 

[medicsb]

Can not give morphine fentanyl or Valium IM on standing orders here.

Versed is far better absorbed IM than Valium anyway... (to my understanding)


While I can't officially diagnose anything the likelihood of a focal or partial seizure with full body convulsions and patients given history is pretty slim to none.

You weren't very clear as to the "jerking in a seizure like fashion" but later posts indicate that his arms were involved. Anyhow, not all patients with alcohol withdrawal experience tonic-clonic seizures and some do experience focal/partial seizures of which the manifestation is dependent on the location of the neurons exhibiting abnormal activity in the brain. They can be purely motor, which could have been what he was experiencing. At the very least, it sounds as if he was experiencing myoclonus. The difference between myoclonus and a partial seizure is hazy to myself. Either way, they both can be treated with a benzodiazepine.

 

[Basermedic159]

So I had a patient at a rehab facility today who was being treated for very long term severe alcohol abuse (30 years)

Originally came in as a seizure but we walked in and the patient is in a chair, jerking in a seizure like fashion but concious, with random outbursts of words paired with a pretty pale look.

He was fully AO and able to hold a conversation with broken sentences. The story was that he has been sober 14 days, but was unable to acquire his prescribed medications due to some restriction to a particular pharmacy, which he could not make it to for one reason or another. He was txp two days prior for the same issue to which the hospital resolved via IM Ativan.

Vitals were
BP - UTO due to muscle activity
HR - 112
RR - 20
SPo2 - 95% room air
EKG - UTO as well.

We were only 10 min from the hospital.

My partner felt it would be a waste of time, so we didn't bother but would it have been worthwhile to call for a discretionary administration of say 5mg of versed IM just to reduce his condition vs sedating him with the usual 10 mg.

We carry versed and Valium here, and an IV was probably a long shot for Valium.

Mind you we do have standing orders to give either if seizure activity occurred, but he obviously wasn't seizing and we don't have standard orders for treating withdrawals regardless of how severe.

I would have established an IV just incase he started to seize. However if the pt was agitated or combative I would have went with versed.

 

[Basermedic159]

Also, I think it would have been up to you as to if you should have administered either benzo. If you thought it would have made a difference in improving his symptoms maybe it would have been a good idea to administer it. I think it just depends on the pt and what you think would be the most appropriate course of action.

 

[systemet]

A sublingual ativan might go a long way to helping the situation.

 

[mycrofft]

After six years in detox ward...

1. ETOH physiologic withdrawl usually starts within 24 hrs of verifiable abstinence. Rarely longer, esp with elevated liver enzymes showing it isn't detoxing alcohol well. By the same token the liver isn't making active metabolites from benzos in those cases , so serial doses may suddenly take effect when the liver ewakes up, if ever. ETOH physiologic detox lasts until the ETOH is gone and the body reequilebrates,which is not slowed or sped by meds unless they further detract from hepatic clearance, prolonging the process. Rule of thumb from observation: one week course of a quick load (six hours) valium followed by a one week taper in 5 mg stages worked just fine for all but the most fubared.
2. The ETOH addicted can have other issues like polypharmacy abuse, psychiatric and psychological issues, malnutrition, and CNS pathology like Korsakoff's Syndrome. Not to mention maladies common to all, and especially to people "living rough", or without aforethought (STD, AIDS, TB, Hepatitis varieties).
3. The ETOH addicted can sometimes mimic S/S to get meds, especially by acting out to frustrate vital signs/assessment.

Get a good series of assessments definitely including chem panel, tox screen, hep antibodies, serial no-foolin' vital signs, and get orders from MD for seizure precautions and mental health workup. In fact, MD needs to see pt asap in any event.

EDIT: fingerstick glucometry and UA not a bad start either. This is not really EMS.

 

[NYMedic828]

1. ETOH physiologic withdrawl usually starts within 24 hrs of verifiable abstinence. Rarely longer, esp with elevated liver enzymes showing it isn't detoxing alcohol well. By the same token the liver isn't making active metabolites from benzos in those cases , so serial doses may suddenly take effect when the liver ewakes up, if ever. ETOH physiologic detox lasts until the ETOH is gone and the body reequilebrates,which is not slowed or sped by meds unless they further detract from hepatic clearance, prolonging the process. Rule of thumb from observation: one week course of a quick load (six hours) valium followed by a one week taper in 5 mg stages worked just fine for all but the most fubared.
2. The ETOH addicted can have other issues like polypharmacy abuse, psychiatric and psychological issues, malnutrition, and CNS pathology like Korsakoff's Syndrome. Not to mention maladies common to all, and especially to people "living rough", or without aforethought (STD, AIDS, TB, Hepatitis varieties).
3. The ETOH addicted can sometimes mimic S/S to get meds, especially by acting out to frustrate vital signs/assessment.

Get a good series of assessments definitely including chem panel, tox screen, hep antibodies, serial no-foolin' vital signs, and get orders from MD for seizure precautions and mental health workup. In fact, MD needs to see pt asap in any event.

EDIT: fingerstick glucometry and UA not a bad start either. This is not really EMS.

lol i was about to say, you have some state of the art stuff going on in the back of your ambulance.

 

[Dr.T]

Those symptoms in the OP sound like "delirium tremens" to me.
I don't know what it is called in medical English, it might even be the same term... I've had lot's of homeless people here show these s/s....
Benzos are the way to go.

 

[systemet]

I don't know what it is called in medical English, it might even be the same term...

It is!

 

[mycrofft]

Let me clarify...I was on the STAFF....



After 14 days ETOH and hence DT's are over. Plus, able to converse means not hallucinating much. Either detoxing meds (what was he on? Verifiable?), or lying about being clean, or lying to get drugs. Or has developed some sort of organic CNS disorder, or is psych (Tourette's Syndrome?).

ETOH withdrawal is not only excitation of the CNS concerning voluntary motor and cognitive activities, but accompanied by GI distress, (NVD, or nausea, vomiting and diarrhea), diaphoresis, cramping pains in various regions as well as in the gut.

We used to laugh at articles and studies talking about needing month for physiologic detox. At least some, if not all, were relying on subjective accounts by detoxing alcoholics for objective data!

(Like that one? You'll howl at articles saying methadone takes months to detox! Same data source).