12.2 Substance Withdrawal, Psychiatric Emergencies & Patient Safety

Alcohol Withdrawal — Timeline, Assessment, and Treatment

Alcohol is the most common substance-withdrawal emergency in the ICU, and untreated delirium tremens (DTs) still carry up to 5-15% mortality. Withdrawal reflects the loss of alcohol's GABA-enhancing, glutamate-suppressing effect, producing central-nervous-system and autonomic hyperexcitability. Symptoms follow a fairly predictable clock from the last drink.

Distinguish alcoholic hallucinosis (12-24 h; hallucinations with a clear sensorium and stable vitals) from DTs (48-96 h; clouded sensorium/disorientation, severe autonomic storm, fever). Withdrawal seizures are typically generalized and early (24-48 h); focal seizures or status epilepticus point to another cause.

CIWA-Ar and Symptom-Triggered Dosing

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) scores 10 items — nausea, tremor, sweats, anxiety, agitation, tactile/auditory/visual disturbances, headache, and orientation — for a maximum of 67. Interpretation: <8-10 minimal, 8-15 moderate, and >15 severe with high seizure/DT risk. Symptom-triggered dosing — giving a benzodiazepine only when the CIWA-Ar crosses a threshold (commonly 8-10) — uses less total drug and shortens treatment versus fixed-schedule dosing, and is preferred whenever the patient can be reliably scored. CIWA-Ar is invalid in the intubated or unassessable patient; use a RASS-based protocol there.

Pharmacologic Management

Benzodiazepines are first-line because of GABA cross-tolerance — lorazepam, diazepam, or chlordiazepoxide. Long-acting agents (diazepam, chlordiazepoxide) give a smoother self-taper, but lorazepam is preferred in hepatic dysfunction or the elderly because it has no active metabolites. Refractory DTs may need phenobarbital or adjunctive propofol (with intubation) plus escalating benzodiazepine doses. Give thiamine before any glucose to prevent Wernicke encephalopathy, and replace folate, magnesium, potassium, and phosphate. Beta-blockers and alpha-2 agonists (clonidine, dexmedetomidine) blunt autonomic symptoms such as tachycardia and hypertension, but they do not correct the GABA deficit and do not prevent seizures or DTs — used alone they can dangerously mask escalating withdrawal.

Opioid and Stimulant Emergencies

Opioid overdose presents with the triad of respiratory depression, pinpoint (miotic) pupils, and depressed consciousness; after supporting ventilation, give naloxone, titrating to restore adequate respirations rather than full alertness so as to avoid precipitated withdrawal. Opioid withdrawal, graded with the COWS scale, is intensely uncomfortable but rarely life-threatening in adults; manage with methadone or buprenorphine and adjuncts such as clonidine.

Stimulant (cocaine, methamphetamine) intoxication produces agitation, hypertension, tachycardia, hyperthermia, seizures, and chest pain from coronary vasospasm (with myocardial infarction or aortic dissection risk). Benzodiazepines are first-line for agitation and cardiovascular symptoms because they reduce sympathetic drive. Classic teaching is to avoid beta-blockers alone in acute cocaine toxicity because of theoretical unopposed alpha-mediated vasoconstriction. Also distinguish toxidromes with hyperthermia and altered mentation: serotonin syndrome (serotonergic agents; clonus, hyperreflexia, rapid onset) versus neuroleptic malignant syndrome (antipsychotics; lead-pipe rigidity, hyporeflexia, slower onset) — both require stopping the offending drug and aggressive cooling.

Psychiatric Emergencies

Suicidal Ideation

Screen directly — asking about suicide does not increase risk. A patient with active ideation, a plan, or intent requires continuous 1:1 observation, a ligature- and means-safe environment (remove cords, sharps, belts, and unsecured medications), immediate provider notification, and psychiatric consultation. Document the risk assessment and every intervention. Never leave the patient alone or rely on a bed alarm alone.

Agitation and De-escalation

For the agitated or potentially violent patient, verbal de-escalation is first-line: approach calmly, keep a safe distance and a clear exit, use a low steady voice, set firm limits, and offer realistic choices. If de-escalation fails and there is imminent danger, escalate to pharmacologic management (a benzodiazepine such as lorazepam, with or without an antipsychotic such as haloperidol), reserving physical restraint for last resort.

Patient Safety — Restraints and Falls

Restraints are a least-restrictive, last-resort intervention used only after less-restrictive measures fail and the patient poses imminent harm (behavioral/violent) or would disrupt life-sustaining therapy such as an endotracheal tube (non-violent/medical-surgical).

Key CMS and Joint Commission rules the CCRN tests: a restraint requires a provider order — never a standing PRN order; for violent/self-destructive restraint a face-to-face evaluation within 1 hour is mandatory, and monitoring includes circulation, skin integrity, range of motion, toileting, hydration, and nutrition, with frequent reassessment (often every 15 minutes for behavioral restraint). Secure ties with quick-release knots to the bed frame, never the side rail, and remember restraints themselves carry harm — asphyxiation, aspiration, nerve/circulatory injury, pressure injury, venous thromboembolism, and worsened agitation and delirium — so discontinue at the earliest safe moment. Fall prevention uses a validated risk tool (Morse Fall Scale or Hendrich II), bed/chair alarms, low beds, nonslip footwear, uncluttered rooms, call-light access, scheduled toileting, and medication review (sedatives, opioids, and benzodiazepines raise risk). Because delirium and immobility drive both falls and further delirium, early mobility and delirium prevention are core safety strategies, not competing ones.