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A 35-year-old female patient presented to the Emergency Department for symptoms consistent with severe alcohol withdrawal. Patient is sweating profusely, has tremors, anxiety, and is physically and verbally intrusive with staff. Her CIWA-Ar score indicates severe withdrawal, and she is at high risk for complications due to a past episode of Delirium Tremens within the last year.

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Vital Signs:

·       Heart rate: 110 bpm

·       Blood pressure: 165/101 mmHg

·       Respiratory rate: 22 breaths/minute

·       Temperature: 37.5°C (99.5°F)

·       Oxygen saturation: 98% on room air

Clinical Institute Withdrawal Assessment for Alcohol Scale-Revised (CIWA-Ar):

·       Nausea and vomiting: 3

·       Tremors: 4

·       Paroxysmal sweats: 4

·       Anxiety: 3

·       Agitation: 5

·       Tactile disturbances (e.g. "bugs crawling on skin"): 3

·       Auditory disturbances (e.g. ringing in the ears): 1

·       Visual disturbances (e.g. "halos" around lights): 0

·       Headache: 1

·       Orientation and cognition (ability to remember the date and place): 1

Total: 25/67

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Participant Names: Soluzu Akpu; Lara Bakarat; Jasmine Cabusao; Jethro Corbes; Katie Driskell; Giselle Gonzalez; Beyonce Mutia; Sarah Stenger

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History of alcohol use disorder.

The last drink was 18 hours ago.

Documented a Delirium Tremens episode in the past year.

Assessed using the CIWA-AR protocol.

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Initiate scheduled benzodiazepine therapy per CIWA-Ar protocol.

Begin banana bag (IV fluids with thiamine, folate, and multivitamins).

Admit to a monitored setting, consider an ICU consult if symptoms escalate or seizures occur.

Continuous monitoring of CIWA-Ar score, vital signs, and mental status

Psych consult may be needed for behavioral concerns and future rehab planning.

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1.) Delirium Tremens

A severe and life-threatening form of alcohol withdrawal.

This patient is high risk due to her history of DTs, high CIWA-Ar score (25), agitation, and elevated vitals.

Symptoms can include confusion, hallucinations, and unstable vital signs.

Typically occurs 48–72 hours after the last drink.

Requires urgent treatment with benzodiazepines and close monitoring.

2.) Withdrawal Seizures

Seizures can occur within 6–48 hours of stopping alcohol.

This patient’s tremors and past DTs suggest a high risk.

Seizures can be sudden and lead to dangerous complications like status epilepticus.

Prevention includes scheduled or symptom-triggered benzodiazepine therapy.

3.) Acute Psychosis or Psychiatric Decompensation

Severe withdrawal can lead to hallucinations, paranoia, or aggression.

This patient has tactile disturbances and high anxiety/agitation, which may progress.

Risk of harm to self or others if symptoms worsen.

Requires psych assessment, calm environment, and possibly antipsychotic support.

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Anticipated order from the provider to address the highest level complication.

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Anticipated order from the provider to address the highest level complication.

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The priority complication would be delirium tremens. The doctor may order IV benzodiazepines (e.g., lorazepam) as needed per CIWA-AR protocol, and baseline labs (CBC, BMP, electrolyte levels).

Rationale:

Delirium Tremens is a severe and potentially life-threatening emergency. IV benzodiazepines help subdue neuronal activity by boosting the effect of GABA. Benzodiazepines can help control the shaking, confusion, increased blood pressure, and risk of seizures.

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The nurse has been carefully titrating lorazepam according to protocol for the 35-year-old patient, who has been pacing the room and muttering repeatedly, “BUGS ARE CRAWLING ON THE CEILING.” Noticing the patient talking to themselves, the nurse then dimmed the lights, reduced environmental stimulation, and maintained 1:1 supervision.

As the nurse was leaving the room, the patient then screams, “AHHH! THEY'RE UNDER MY SKIN” in a panic and rips out her IV. She starts flailing, knocks over a monitor, and collapses to the ground. A tonic-clonic seizure ensues, lasting nearly a minute. Afterwards, she is disoriented, diaphoretic, nonverbal, and attempting to crawl under the bed, screaming about fire and insects.

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HR: 142 bpm

BP: 198/113 mmHg

RR: 28

Temp: 38.6°C (101.5°F)

CIWA-Ar now ≥ 25

IT'S TIME TO ACT FAST!

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1) Delirium Tremens:

Administer medications as ordered based on CIWA-AR score, monitor vital signs frequently, provide a low-stimulation environment.

Rationale:

Benzodiazepines can prevent progression of delirium tremens. Frequent VS checks allow early detection of autonomic hyperactivity and a calm environment reduces sensory overload and agitation.

2) Withdrawal Seizures:

Initiate seizure precautions, continue medication therapy per protocol, and monitor neurological status and LOC regularly.

Rationale:

Seizure precautions reduce the risk of injury during seizures, medications can reduce neuronal excitability, and ongoing neuro checks help detect early signs of seizures or worsening withdrawal.

3) Acute Psychosis or Psychiatric Decompensation:

Request a psychiatric consult and assess mental status frequently, use a calm, non-confrontational approach with de-escalation techniques, and ensure close supervision or initiate a sitter, if needed.

Rationale:

Psych evaluations and monitoring can identify worsening psych symptoms so they can be treated appropriately. A calm approach reduces anxiety and risk of aggression, supervision ensures safety if the patient becomes a danger to self or others.

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3 nursing actions you will take to facilitate a transition to a higher level of care

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3 nursing actions you will take to facilitate a transition to a higher level of care

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The highest priority is to stabilize and ensure the patient's safety. It is important to start administering IV lorazepam (Ativan) per seizure/emergency protocol. It is also important to protect the patient's airway by making sure they are lying on their side, applying oxygen, and initiating seizure precautions.

Rationale: Ensure patient survival and prevent aspiration or prolonged CNS complications due to the seizure and delirium.

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After activating the Rapid Response Team and ensuring the provider has been notified, it is now time to initiate transfer to the ICU to ensure the patient's safety and continuity of care. Confirm that all monitoring devices (telemetry, pulse oximetry, blood pressure cuff) are in place and functioning. Provide a thorough SBAR report to the ICU nurse, including the patient's current LOC and changes observed, the interventions that have been performed, and any relevant medical history.

Rationale: The patient requires ICU-level care for continuous IV sedation, close neurologic and cardiovascular monitoring (telemetry), seizure control, and potential airway support. Prompt and thorough handoff ensures safe transition and prevents further deterioration.

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It is now time to leave the unit. Ensure that all of the important patient paperwork is brought. If the patient remains combative or disoriented, ensure that the necessary security and staff are present to assist with the transport.

Rationale: A medically and behaviorally unstable patient presents a risk to themselves and others. Ensuring proper documentation and secure transport supports safe handoff and uninterrupted continuity of care in the ICU.