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ALCOHOL AND THE EMERGENCY DEPARTMENT.

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Title: MANAGING ALCOHOL WITHDRAWAL AND WERNICKES ENCEPALOPATHY IN THE EMERGENCY DEPARTMENT. Author: Harrisonlx Last modified by: AMD UWE Created Date – PowerPoint PPT presentation

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Title: ALCOHOL AND THE EMERGENCY DEPARTMENT.


1
ALCOHOL AND THE EMERGENCY DEPARTMENT.
  • LUCY HARRISON
  • Alcohol CNS
  • Ext 21487, bleep 6110
  • July 2014

2
AIMS OF SESSION
  • 1. To understand why we need to ask all patients
    who attend the ED about their alcohol use.
  • 2. Who has problems with alcohol?
  • 3. How do we ask people about their alcohol use?
  • 4. How to detect possible dependence to alcohol?
  • 5. How do we manage alcohol dependant patients in
    the ED?
  • 6. Non dependant patients.

3
WHY WORRY...
4
WHY WE SHOULD WORRY ABOUT ALCOHOL...
  • Alcohol costs the NHS 2.7 billion per year.
  • Recent reports indicate that 10.5 million adults
    drink above the recommended limits.
  • Alcohol is the 3rd leading cause of disease
    burden in developed countries.
  • There are over a million hospital admissions due
    to alcohol each year in England. In 2009/10
    20,032 individuals in Bristol were admitted to
    hospital either wholly or partly due to alcohol.

5
  • WHAT SORT OF ED PRESENTATIONS COULD BE ALCOHOL
    RELATED?

6
TOP 10 ALCOHOL RELATED PRESENTATIONS
  • Fall
  • Accident
  • Collapse
  • Head Injury
  • Assault
  • Unwell
  • Gastro Intestinal
  • Cardiac
  • Psychiatric ( including OD/DSH)
  • Repeat attendee
    Touquet et al (2009)

7
  • Who has problems with alcohol?


8

9
(No Transcript)
10
  • ACCORDING TO GOOGLE
  • Jonny Depp, Russell Brand, Michael J Fox,
    Davina McCall, David Hasselhoff, Mel Gibson,
    Robin Williams, Steven King, Tara
    Palmer-Tomkinson, Florence Welch, Kelly Osbourne,
    Frank Skinner, Ben Affleck, Denzel Washington,
    Ewan McGregor, Diana Ross, Matthew Perry, Eminem,
    Christina Ricci, Simon Pegg, Kate Moss, Daniel
    Radcliffe, Jada Pinket-Smith, Kristin Davis, Drew
    Barrimore, Eva Mendes, Micha Barton, Angelina
    Jolie, George Clooney, Sadie Frost, Katie Perry,
    Anne Robinson, Kirsten Dunst, Demi Moore, Charlie
    Sheen, Tara Reid, Oprah Winfrey, Mike Tyson,
    Damien Hurst, Nicole Ritchie, Winona Ryder, Cory
    Monteith, Jamie Lee-Curtis, Jemima French, Jim
    Carey, Mark Owen, Tom Chaplain, Toby Maguire,
    Naomi Campbell, Alex James, Gerard Butler, Gazza,
    Pearl Lowe, David Bowie, Shaun Ryder, Colin
    Farrell, Brittany Spears, Anthony Hopkins, Pete
    Doherty, Robbie Williams, Sarah Harding, Graham
    Coxon

11
WHY DO WE NEED TO ASK ABOUT ALCOHOL USE?
  • To be able to manage patients care safely while
    in the department.
  • To be able to offer support/ advice etc around
    patients alcohol use if they feel it is
    required. This can help to reduce further
    hospital attendances in the long run.
  • The ensure that patients are aware of the risks
    involved in regularly drinking more than the
    recommended amounts.

12
HOW DO WE ASK PEOPLE ABOUT THEIR ALCOHOL USE?
  • Use of the Paddington Alcohol Test (PAT).
  • Consists of three questions.
  • Takes very little time to do.
  • Anyone can complete it.
  • Anyone who is PAT positive should be asked if
    they would like to see the alcohol nurse
    specialist.
  • Anyone who is PAT positive leads you to consider
    more questions about a patients alcohol use eg,
    is there concern that there maybe a dependence to
    alcohol?

13
RECOGNISING ALCOHOL DEPENDENCE
  • Patients who experience 3 or more of the
    following symptoms are likely to have alcohol
    dependence
  • A strong desire or compulsion to drink.
  • Difficulty in controlling levels of alcohol use.
  • Experience of physical withdrawal on stopping
    alcohol use.
  • Increased tolerance to alcohol.
  • Neglect of other interests eg eating or washing.

14
SYMPTOMS OF UNCOMPLICATED ALCOHOL WITHDRAWAL
  • Tremor
  • Fever
  • Anxiety
  • Insomnia
  • Sweating
  • Nausea/ vomiting
  • Agitation/ irritability
  • Tachycardia
  • Hallucinations
  • Mild systolic hypertension
  • Symptoms of withdrawal can be seen within 6-8
    hours of the last alcoholic drink. They peak at
    10-30 hours, and usually begin to stop at 30-40
    hours.

15
DELIRIUM TREMENS (DTS)
  • DTs only occur in around 5 of patients
    experiencing alcohol withdrawal, but account for
    a high rate of mortality. DTs represent a
    medical emergency, and usually have an onset 2-3
    days post the last alcoholic drink.
  • Symptoms of DTs
  • Auditory and visual hallucinations.
  • Confusion and disorientation
  • Severe tremors
  • Delusion
  • Agitation
  • Tachycardia
  • Fever
  • Hypertension

16
ALCOHOL RELATED SEIZURES
  • Seizures can be another symptom of alcohol
    withdrawal, but are rare beyond 48 hours after
    the last alcoholic drink. Consider admission if
    it is the first ever instance, otherwise base
    treatment on the severity of the seizure and
    observed recovery.

17
MANAGING ALCOHOL WITHDRAWAL
  • Chlordiazepoxide is used to treat alcohol
    withdrawal.
  • 20-40mg of chlordiazepoxide QDS depending on
    level of alcohol use. Additional PRN
    chlordiazepoxide should be considered, up to
    240mg in total can be given in a 24 hour period.
  • If symptoms persist, consider lorazepam or
    haloperidol.
  • (prescribing guidance for chlordiazepoxide is on
    the DMS)

18
WERNIKES ENCEPHALOPATHY
  • Wernikes encephalopathy is caused by thiamine
    deficiency, but can be reversible if treated
    early. It is also very difficult to diagnose,
    especially if the patient is intoxicated. As
    there is no simple test for wernikes
    encephalopathy, all patients with evidence of
    chronic alcohol misuse should be prescribed
    pabrinex.
  • IV Pabrinex 1and 2, 2 pairs TDS.
  • (Prescribing guidance is on DMS)

19
??TTA CHLORDIAZEPOXIDE??
  • TTA chlordiazepoxide should not be prescribed to
    patients being discharged from the ED.
  • Once discharged from the ED, patients should be
    advised to contact their GP and offered an
    appointment with the alcohol nurse specialist.
    They should be advised to continue drinking until
    they have the support of specialist services to
    help them detox safely. They should be advised of
    the risks of stopping drinking suddenly. Please
    give out the advice leaflet on this.

20
NON DEPENDANT PATIENTS
  • Alcohol can still cause harm and be problematic
    even if the patient is not alcohol dependant...
  • They can still benefit from our advice and
    support.

21
THINK ABOUT THE BIGGER PICTURE
  • Does alcohol have an impact on your patients
    health and wellbeing, is it likely to in the
    future?
  • Is alcohol stopping your patient from meeting
    their own basic needs?
  • (Maslows Hierarchy Of Needs)
  • Remember to consider the effect alcohol may be
    having on others too

22
  • Please refer to the drug and alcohol connect site
    for advice/ information and for links to alcohol
    related information leaflets.
  • There is a Smart Recovery group run by the drug
    and alcohol nurses every Wednesday evening
    (Queens building, level 4, clinic 9).
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