EtOH withdraw, seizures, phenobarb and your comfort level

[WilcoWorld]

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Florid DTs clearly not

Initially read this as "Florida DT's" and thought - yeah, those sound bad.

 

[WilcoWorld]

They might have decision making capacity.

Agreed, capacity is not that simple.

 

[thegenius]

You call security. They do not have decision making capacity if they have alcohol withdrawal.

That's not necessarily true. Blanket statements like this can get one in trouble. Not mad at ya, just saying. There's a spectrum with everything. In my experience most (> 90%) of those that we diagnose with alcohol withdraw in my experience very likely have capacity to make medical decisions...i.e. they are not seizing or floridly hallucinating

 

[Candidate2017]

Florid DTs clearly not, but a mildly tremulous patient with clear sensorium and without SI/HI who says look, I’m not staying I just want to go out and drink. We strap that guy down against his will?

Yes, in the ED they may or may not have capacity.

From the floor perspective patients in W/D almost never have capacity by the time I get receive the consult and see them the next day: It's been almost 24 hrs since admission + whatever time since last drink, and CIWA protocol hasn't helped. So they are in W/D close to DTs, if not in DTs.

 

[Candidate2017]

It turned into 2 weeks because you're using Precedex for alcohol withdrawal. Don't do that, it is one of the worst possible medications you can give to an individual in acute withdrawals.

That's what I said. ICU gonna ICU though.

 

[BoardingDoc]

It turned into 2 weeks because you're using Precedex for alcohol withdrawal. Don't do that, it is one of the worst possible medications you can give to an individual in acute withdrawals.

It is the equivalent of only giving a septic patient a dose of tylenol and a beta blocker rather than abx and fluids and claiming you're treating them because their HR and temp have improved.

Elaborate. You're anti-precidex completely in withdrawal? Or just as monotherapy. The latter, yes, is absurd. As an adjunct to benzos/Barbs if you aren't getting effective sx control with those alone and you don't want to intubate the patient, that seems reasonable to me. That said, I'm not an ICU doc so maybe I'm missing something here.

 

[RustedFox]

What's Precedex?

EDIT: /sarcasm. It's just that its not anything that we'd use in my ER.
My EtOH withdrawal patients (which are many... I'm pretty sure I work in a level-1 EtOH withdrawal center) all get loaded up with ativan and then passed on to the IM/CC folks.

 

[TooMuchResearch]

Agreed, capacity is not that simple.

Like I think I mentioned before, there is a guy my group has intubated multiple times the past year, but sometimes he just has a seizure and a little withdrawal and then let's us know he's going home.

 

[Zebra Hunter]

Elaborate. You're anti-precidex completely in withdrawal? Or just as monotherapy. The latter, yes, is absurd. As an adjunct to benzos/Barbs if you aren't getting effective sx control with those alone and you don't want to intubate the patient, that seems reasonable to me. That said, I'm not an ICU doc so maybe I'm missing something here.

I am against precedex entirely. It masks symptoms of withdrawals which are our best indicator of when to give additional benzos or barbs. If you have to intubate then do it, although if they are still significantly symptomatic it is unlikely that you are going to cause respiratory depression. The other issue with starting precedex in the situation you describe is that unless you schedule benzos blindly for the patient, they will have very low CIWA scores and the ICU will end up not giving the patient anymore benzos, which leads to prolonged hospital stays, seizures, and potentially even death.