Alcoholic Presentation Scenario (Technician)

Would you deem this patient to have capacity?

You slowly and gently complete a set of observations whilst still trying to talk to the patient and reassuring them about what is happening. You gain observations of: 122HR, 153/86 BP, 22RR, 98% Sp02, 4.5 BM, 37.1 Temperature. 

What is this patient’s NEWS score? 

The patient seems to regain some focus and starts to speak with you slowly, in very small sentences. He explains he is very itchy (which you have noted lots of itching) and keeps seeing hordes of spiders crawling along the walls of the room and hearing voices. You gain a few bits of information including no allergies, past medical history of 2x pancreatitis as well as alcohol dependant, and only medication taken regularly is Thiamine as he is not compliant on other drugs he has been prescribed. However, as you look to ask further questions about his recent history, his focus goes elsewhere again and starts to look agitated. 

What do you think is the more likely diagnosis for this patient and their current presentation? 

You suspect this is ticking a few signs and symptoms of alcohol withdrawal. Your crewmate has looked around the house and states he can’t find any alcohol bottles or cans anywhere which help confirm your suspicions. On this evidence, would you be able exclude other differentials and continue to treat down an alcohol withdrawal route? 

You are aware that you will still need to consider other differentials throughout as you have been unable to complete any history taking. What differentials may present similarly to alcohol withdrawal?

You keep your differentials in the back of your mind whilst you continue your assessment. The patient seems to regain focus again and you quickly ask when was the last time they had alcohol? They state yesterday. 

What complication of alcohol withdrawal syndrome is of most concern to emergency clinicians and needs to be treated promptly? 

How long after alcohol cessation does the patient normally present with alcohol withdrawal seizures?

What tool can be used to help determine the severity of a patient’s alcohol withdrawal syndrome?

You use the CIWA-Ar score to help determine your patient’s severity. You get the following answers… 

They have intermittent nausea, they have no visible tremor but it can be felt fingertip to fingertip, they are moderately anxious, they are somewhat fidgety and restless. The patient is not sweaty, they are disorientated to date but are only one day out, they have moderate visual hallucinations and moderate auditory hallucinations, they have no visual sensitivity, and he has a very mild headache. 

What severity would this patient’s alcohol withdrawal be classed as? 

You have determined the patient is at the more severe end of alcohol withdrawal, what management plan is recommended by NICE guidelines?

What tool can be used to help determine severity if the patient cannot participate in the CIWA-Ar assessment?

The progression of a patient’s symptoms into alcohol withdrawal delirium (fever, tachycardia, agitation, diaphoresis, hallucinations, disorientation, hypertension) is associated with a higher mortality rate due to a risk of cardiovascular collapse?

Which treatment listed below will reduce the risk of progression of a patient with alcohol withdrawal?

Is diazepam administration indicated for alcohol withdrawal syndrome with tremors in JRCALC?

Alcohol use increases GABA release, a primary inhibitory neurotransmitter. When used chronically then suddenly stopped, the GABA production also stops suddenly and causes an overstimulation and autonomic hyperactive state?

Ambulance clinicians should actively stop a patient with alcohol withdrawal symptoms from drinking alcohol?