FUENTES DE INFORMACIÓN

•Atthefirstsignofwhatappearstobeaseizure,laywitnessesshouldsummontrainedmedicalpersonnel. •Dependingonthesetting,thismaymeancalling911orcallingthenurseorphysicianwhoisondutyfor

theclinicorhospitalunit.

•Whileawaitingmedicalhelp,alaypersonwitnessinganalcoholwithdrawalseizureshouldgentlyattempt topreventinjurytothepersonasheorsheslumpsorfallstothefloorbyprotectingtheindividual’shead andbodyfromhardorsharpobjects.Often,though,theinitiallossofconsciousnessandfallisnotseen byanyone.

•Inthejerkingphaseoftheseizure,ifthejerkingisextreme,itisimportanttoprotecttheheadfrom extremehead-bangingbyplacingasoftobjectundertheheadandneck.Sometimesplacingone’shandor shoeundertheheadisadequate.

•Noattemptshouldbemadetoinsertanythinginthemouth(suchasspoons,pencils,pens,tongueblades). Suchattemptsatobjectinsertionmaycausedamagetotheteethandtongue,orobjectsmaygetpartially swallowedandobstructtheairway.

•Patientswhostarttoretchorvomitshouldbegentlyplacedontheirsidesothatthevomitus(stomach contentsvomited)mayexitthemouthandnotbetakenintothelungs.Vomitustakenintothelungsisa severemedicalconditionleadingtoimmediatedifficultybreathingand,withinhours,severepneumonia. •Eveniftheindividualappearstobecomefullyawake,alert,andorientedwithoutanyharmfollowinga

seizure,itisstronglyrecommendedthathebereferredformedicalevaluation.

•Individualswhoawakenconfusedanddisorientedshouldbegivenbriefreassuringandsoothingmessages toreorientthemastowhathappenedandwheretheyare.

•Havingdrunkformorethantwodecades •Havingpoorgeneralmedicalhealthandpoor

nutritionalstatus

•Havinghadpreviousheadinjuries

•Havinghaddisturbancesofserumcalcium, sodium,potassium,ormagnesium

Patientshavingawitnessedseizurecanbe treatedwithIVdiazepamorlorazepamand ACLSprotocolprocedures.Thisreducesbut doesnotcompletelypreventthelikelihoodofa secondseizure(D’Onofrioetal.1999).Inthe rarepatientwithrecurrentmultipleseizuresor statusepilepticus(continuousseizuresofsever- alminutes)ananesthesiologyconsultationmay berequiredforgeneralanesthesia.Evaluation ofelectrolytedisturbances,centralnervoussys- tem(CNS)trauma,andconsiderationofseda- tive-hypnoticwithdrawalshouldbereviewed. Patients who have had a single witnessed or suspected alcohol withdrawal seizure should be immediately given a benzodiazepine,

preferably with IV administration. The study by D’Onofrio and colleagues (1999) indicated that a single dose of 1mg of IV lorazepam reduced recurrent seizure risk, reduced rates of return to emergency departments, and low- ered hospitalization rates. Despite this

report, the consensus panel agrees that hospi- talization for further detoxification treatment is strongly advised to monitor and ameliorate other withdrawal symptoms, reduce suffering, and stabilize the patient for rehabilitation treatment.

The addition of anti-epileptic drugs (AEDs) has not been established as effective (Chance 1991; Hillbom and Hjelm-Jager 1984; Rathlev et al. 1994). This is primarily based on evalu- ations of phenytoin (Dilantin and others). Newer AEDs have not been studied extensive- ly for preventing alcohol withdrawal seizures. The consensus panel suggests that AED thera- py should be considered in alcohol withdraw- al patients with multiple past seizures (of any cause), a history of recent head injury, past

meningitis, encephalitis, or family history of seizures. Further evaluation of a first seizure often warrants neurologic evaluation (com- puterized tomography and electroencephalo- gram), even if the seizure may be suspected to have been due to alcohol withdrawal.

Patient

Care

and

Comfort

Interpersonalsupportandhygieniccarealong withadequatenutritionshouldbeprovided. Staffassistingpatientsindetoxificationshould providewhateverassistanceisnecessaryto helpgetpatientscleanedupafterenteringthe facilityandbathedthoroughlyassoonasthey havebeenmedicallystabilized.Attentiontothe treatmentofscabies,bodylice,andotherskin conditionsshouldbegiven.Screeningfor tuberculosisshouldbedone.Dentalandoral careshouldbemadeavailable.Thepatient shouldbescreenedforphysicaltrauma, includingbruisesandlacerations.Tetanus immunizationmaybenecessary.Patientswith analteredmentalstatusoralteredlevelofcon- sciousnessshouldbeseeninemergencydepart- ments,evaluated,andpossiblyhospitalized. Staffshouldcontinuetoobservepatientsfor headinjuriesafteradmissionbecausesome headinjuries,suchassubduralhematomas, maynotimmediatelybeevidentandcostcon- siderationsmayprecludeobtainingabrain scaninsomesettings.

Other

Immediate

Concerns

Alcoholmayinteractwithseveralclassesof medicinetoproduceseriousCNSdepression. Someexamplesincludebenzodiazepines,barbi- turates,meprobamate,andothersedativehyp- noticgroups.Metoclopramideandsedating antipsychoticmedicinessuchasphenothiazines alsocanproduceCNSsuppression.Adisulfi- ram-like(Antabuse)reactioncharacterizedby flushing,sweating,tachycardia,nausea,and chestpainhasbeenreportedformetronidazole andseveralantibioticsincluding,butnotlimit- edto,cefamandole,cefoperazone,andcefote- tan.Acetaminopheninlowdosesmayact acutelywithalcoholtoproducehepatotoxicity (liverdamage).Cliniciansalsoshoulddeter-

minewhetherthepatientisusingaspirinor nonsteroidalanti-inflammatorymedications (forexample,MotrinorAdvil,bothcontaining ibuprofen)inconjunctionwithalcoholuse. Antidiabeticagentsinconcertwithalcoholmay producehypoglycemia(lowbloodsugar)and lacticacidosis(bloodthathasbecometoo acidic).Thetherapeuticefficacyandmarginof safetyfortheuseofanti-anxietymedications, antidepressants,andantipsychoticmedication isthoughtbysometobelessenedbyalcohol use,butthisisbasedlargelyonanecdotal information.Alcoholinteractswithnumerous otherclassesofmedicationsthatleadtoless seriousresults.Someimportantexamplesare sedatives,tranquilizers,antiseizuremedica- tions,andanticoagulants(bloodthinners)such asCoumadin.Patientswhomaybetakingsuch medicationsneedtobecarefullyobservedand havetheirmedicationscarefullymonitored.

Opioids

Opioidsarehighlyaddicting,andtheirchronic useleadstowithdrawalsymptomsthat,

althoughnotmedicallydangerous,canbehigh- lyunpleasantandproduceintensediscomfort. Allopioids(e.g.,heroin,morphine,hydromor- phone,oxycodone,codeine,andmethadone) producesimilareffectsbyinteractingwith endogenous(producedbythebodyitself)opi- oid(:, *,and 6)receptors(thatis,specificsites oncellswherethesesubstancesbindtothe cell).Opioidagonistsstimulatethesereceptors andopioidantagonistsblockthem,preventing theiraction.

Opioid

Withdrawal

Symptoms

Allopioidagentsproducesimilarwithdrawal signsandsymptomswithsomevariancein severity,timeofonset,anddurationofsymp- tomatology,dependingontheagentused,the durationofuse,thedailydose,andtheinterval betweendoses.Forinstance,heroinwithdrawal typicallybegins8to12hoursafterthelast heroindoseandsubsideswithinaperiodof3 to5days.Methadonewithdrawaltypically begins36to48hoursafterthelastdose,peaks

afterabout3days,andgraduallysubsidesover aperiodof3weeksorlonger.Physiological, genetic,andpsychologicalfactorscansignifi- cantlyaffectintoxicationandwithdrawalsever- ity.Figure4-4summarizesmanyofthecom- monsignsandsymptomsofopioidintoxication andwithdrawal.

The clinician uses intoxication and withdraw- al measures as guides to avoid under- or over- medicating patients during medically super- vised detoxification; the number and intensity of signs determine the severity of opioid with- drawal. It is important to appreciate that untreated opioid withdrawal gradually builds in severity of signs and symptoms and then diminishes in a self-limited manner. Repeated assessments should be made during detoxifi- cation to determine whether symptoms are improving or worsening. Repeated assess- ments also should address the effectiveness of pharmacological interventions. Detoxification strategies should aim to establish control over

the opioid withdrawal syndrome, after which dose reductions can be made gradually. Medical complications associated with opioid withdrawal can develop and should be quick- ly identified and treated. Unlike alcohol and sedative withdrawal, uncomplicated opioid withdrawal is not life-threatening. Rarely, severe gastrointestinal symptoms produced by opioid withdrawal, such as vomiting or diar- rhea, can lead to dehydration or electrolyte imbalance. Most individuals can be treated with oral fluids, especially fluids containing electrolytes, and some might require intra- venous therapies. In addition, underlying cardiac illness could be made worse in the presence of the autonomic arousal (increased blood pressure, increased pulse, sweating) that is characteristic of opioid withdrawal. Fever may be present during opioid with- drawal and typically will respond to detoxifi- cation. Other causes of fever should be evalu- ated, particularly with intravenous users,

Figure 4-4