Withdrawal: Stages, Symptoms and Pathophysiology (Nursing)

00:01 So, let's think about these stages.

00:03 We have the first stage which is the early hours, maybe the first eight, six, eight hours.

00:12 We have that second stage that they move into where now, it's between 12 and 48 hours since their last drink and we start seeing that tachycardia.

00:24 We start seeing that restlessness, that irritability.

00:27 When they get into stage three which is normally two to three days after the last drink, we have to really intervene.

00:38 This is where we're going to really move into all those organs beginning to get involved and especially the brain, the hallucinations and the other irritability and acting out.

00:53 One of the other things to remember is that people, because of the stigma that is placed on alcohol use disorder, people are not going to tell you on admission when they're coming in to have surgery that they normally drink a pint of alcohol a night.

01:13 You're going to have to get in and have this therapeutic communication where you're able to talk to them and ask the questions that you need to ask.

01:25 Most hospitals now are going to be asking the CAGE questions which we will get to.

01:46 And if you know that the person is using alcohol on a daily basis, you might want to have the CIWA which we will also be talking about.

01:55 But a person is not usually admitted because of alcohol use disorder to a general hospital.

02:04 A person with alcohol use disorder, when they realize that they just can't do this alone, they might put themselves into a detox and that would be a program that's specifically geared to the person who has alcohol use disorder and it provides them with the medications that they need and we watch them carefully to make sure that they don't have access and we carry them through the withdrawal phase and we bring them through to the other side and try to give them some strategies to help them to remain in recovery from alcohol use disorder.

02:41 But for most nurses, you're going to see them in the hospital because they've been admitted for something else.

02:47 Perhaps during a period of time when they were inebriated, they fell and broke a leg and that break is really bad and they didn't feel so bad and they walked on it and broke it even further.

03:01 By the time they're coming into the emergency room, this person who looks like everyone else, it's within that first six to eight hours that you're going to start noticing something happening.

03:15 And then, you need to be able to intervene.

03:21 Fifty percent of people who have alcohol use disorders, 50% are going to have symptoms of alcohol withdrawal.

03:32 It's our job to be aware of what those symptoms look like and to be on top of them so they don't progress.

03:40 Think of it like a heart attack. If you have a patient in the hospital and that patient says to you, "You know, I'm starting to feel a little dizzy, a little short of breath.

03:51 There's a little bit of like pressure." You're not going to shrug it off.

03:57 You're going to take their blood pressure.

03:59 You're going to take their pulse and you're going to notify someone that there are these symptoms that you're seeing.

04:07 You also want to remember that those people with alcohol use disorder, because of the brain involvement, if it is not treated, they will go into seizures.

04:18 They will have grand mal seizures. They might become delirious.

04:23 So, within a period of a few hours, they may go from talking to you to completely delirious, hallucinating and then, have convulsions.

04:35 Now, this is not something that happens in most of the patients who are going through withdrawal but it does happen in 3 to 5%.

04:44 And during the pandemic, use of alcohol has greatly increased.

04:50 We don't have numbers yet in 2021 on the level of increase for alcohol use disorder but we do know that it is being seen far more frequently than it had been before.

05:05 So, what is our goal? Our goal is to have early recognition.

05:09 This is our goal in every single disorder, whether it is alcohol use disorder or whether it is a heart attack.

05:19 Early recognition and appropriate treatment is paramount.

05:24 So, since we want early recognition, let's think of what we're going to see.

05:30 What are we going to see in this patient? What are those withdrawal symptoms that we're going to see early on? Well, one might be insomnia. Why insomnia? Because remember, alcohol is a CNS depressant.

05:42 So, when people drink alcohol, they actually fall asleep because everything becomes depressed, everything slows down.

05:50 It is generalized. Now, if your body's used to that and we take that away, what happens is this insomnia, this rebound of not being able to calm down, not being able to be relaxed.

06:04 So, now, we're going to see an increase in anxiety as well.

06:08 Your pulse rate is going to start going up.

06:13 This is not sleeping, this is anxiety, and now, we're seeing it affecting your circulatory and heart.

06:22 So, what happens when your heart and your circulation start becoming impacted? Your lungs get drawn in there, too. So, now, we have tachycardia.

06:33 We have tachypnea. The person's pulse is up, their breathing is up.

06:38 They're anxious. They're insomnic.

06:41 Now, if this person is doing this and they say, "Oh, you know, I've just sort of been anxious lately.

06:47 I had this surgery and now, I'm really anxious.

06:50 You might not think this is alcohol use disorder first stages of withdrawal.

06:57 Then, their body temperature starts rising.

07:01 So, when we're looking at this and we're seeing the blood pressure go up, the pulse go up, the respirations go up, they're anxious, they're restless, they can't sleep and now, we see a body temperature rise, if this is post-operative, we're thinking, "Oh, they must have some generalized infection." When in fact, it is not an infection and if we haven't taken a good physical and history on this person, if we haven't connected with them where they trust us to be able to say, "Do you think maybe I could get a glass of wine or something because I usually have four or five with dinner?" We would not know that what we're looking at is the early symptoms of withdrawal.

07:48 And then, of course, there are those hand tremors. That is still early.

07:53 Now, a person who has chronic use and we call them "functional alcoholics".

07:58 People who have their drinks every single day and somehow wake up in the morning and go to work and are able to function in their job and then, as soon as they get off their job, they go and they have their drinks and they make sure, because remember, four to six hours before you start seeing withdrawal, so, if you are working an eight hour day and you take off for lunch, you can have drinks with lunch.

08:22 This can keep you on your - without any withdrawal.

08:27 When they come into the hospital, they may have tremors without any of the other withdrawal symptoms.

08:34 It is a first indicator if you see somebody with hand tremors, to find out whether they have a neurological condition or not.

08:44 Let's think about the pathophysiology of alcohol withdrawal. Why does this happen? Why does the body come out and sort of attack itself? Well, let's remember, remember, I said it twice already but three is the charm.

09:02 Alcohol is a central nervous system depressant.

09:07 And although it's similar to Benzodiazepines and Barbiturates, alcohol is very short-acting.

09:16 It only has an impact for about eight hours but for those eight hours, your full central nervous system is depressed.

09:29 Why? Because the ingestion of alcohol impacts the GABA in the brain.

09:36 Y-aminobutyric acid is GABA and when we have the effects of GABA, what we find is that GABA will reduce our responses.

09:53 It actually as a glutamate-receptor, it actually inhibits our postsynaptic N-methy-D-aspartate glutamate-receptor activity and that is how it actually allows our full nervous system to become depressed.

10:14 Now, as we continue to expose our brains to alcohol, the brain starts to adapt and what it does is it lets all those GABA receptors start changing in the way they relate to the other proteins and these adaptations result in the decrease effect of a depressant.

10:38 So, what does that mean? The higher doses of a depressant are needed in order to get that similar result.

10:47 So, that's the tolerance that we see.