Types of Patients X: Alcohol Detox

Despite (or maybe because of) its status as a legal drug, alcohol consumption is nearly culturally universal, as is addiction and abuse, and the health complications of alcohol use occur across the lifespan.

Although recent research has shown that certain races and individuals with specific genetic profiles may be predisposed to alcoholism, defined as physical dependency upon ethyl alcohol (ETOH), the social and psychological aspects of alcohol addiction exist in all races and cultures.

As well, whereas legal consumption of alcohol is restricted in most societies to certain age groups, the negative health consequences of alcohol use effect all age groups. From alcohol-related accidents to fetal alcohol sydrome (FAS) to liver disease, etc., alcohol consumption, excessive or not, results in untold costs in terms of lives and health care dollars.

One group of individuals often ignored when we talk about the effects of alcohol addicition and abuse is, ironically, the addict. News stories and statistics usually track the unintended victims of abuse--sober accident victims, infants born with FAS--but addicts themselves are usually blamed for their problem and therefore the negative health effects of alcoholism upon them are usually assumed to be chosen, inexcusable, unnecessary...ultimately, a drain on the health care system.

For this reason, alcoholics seeking treatment for alcoholism present a challenge of compassion to ER nurses. Usually we treat patients whose injuries or illnesses are unintentional. With alcoholism, we treat an illness that is the result of the patient's volition. Other illnesses are similarly the result of individual's choices--smoking and lung disease, obesity and just about everything else!--but addiction to alcohol (or other drugs) seems a less sympathetic and more dangerous consequence of an obnxious habit.

I focus on the physical aspects of alcoholism and the nursing interventions necessary to protect the patient seeking detox from the untoward side effects not of alcohol abuse but of the detox process, itself. Attention to the psychological aspects of alcohol abuse and addiction is a more proper intervention while the patient is inpatient, not in the ER. Therefore, aside from supporting the patient's decision to seek detox, I leave philosophical and psychological discussions out of my nursing care.

A-B-C-Ds. Not hard. Usually patients seeking detox are functional, at least from the standpoint of body functions.

However, in the secondary survey (a nursing assessment that takes place after the primary ABCs are assessed and intervened, if neccessary), the D indicates differential diagnosis and/or disability. Aside from the psychological difficulty of breaking a habit, there are potential physical dangers to the patient attempting detox. The initial intervention for these occurs in the ER.

Alcoholics are often relatively malnourished and the sudden cessation of drinking can induce biochemical changes with serious side effects. The most serious side effect is seizure activity. Relative deficiencies in various B-complex vitamins due to malabsorption, specifically Thiamine and Folic acid, predispose the patient to seizures.

Nursing, therefore, must intervene by administering these essential nutrients, usually via IV, and engaging seizure precautions: intravenous access, oxygen and suction supplies at the bedside, and the administration of a benzodiazepine. Usually lorazepam is used because it has both sedative/anticonvulsant as well as anti-anxiety properties.

The anxiolytic property is necessary to permit the patient to get beyond the physical effects (mostly euphoria) of alcohol intake that are often the source of compulsive drinking. The more anxiety the patient experiences, the more likely their decision to detox wanes. Successful detox, therefore, relies upon the transient use of a substitute drug.

Basic lab work is also necessary before the patient is admitted. Complete blood count (CBC), comprehensive metabolic panel (CMP), blood alcohol content (BAC, or medical ETOH), and a urinary drug assay.

The rest, of course, is up to the patient. I can treat detox patients but I can't ultimately detox them. They have to do that for themselves.