J.G.

, a 49-year-old man, was seen in the emergency department (ED) 2 days ago, diagnosed with
alcohol intoxication, and released after 8 hours to his brother's care. He was brought back to the
ED 12 hours ago with an active gastrointestinal (GI) bleed and is being admitted to the intensive
care unit (ICU); his diagnosis is upper GI bleed and alcohol intoxication. You are assigned to
admit and care for J.G. for the remainder of your shift. According to the ED notes, his admission
vital signs were BP 84/56 mm Hg, P 110 bpm, R 26, and he was vomiting bright red blood. He
was given IV fluids and transfused 6 units of packed red blood cells (PRBCs) in the ED. On
initial assessment, you note that J.G.'s VS are blood pressure BP 154/90 mm Hg, P 110 bpm; he
has a slight tremor in his hands, and he appears anxious. He complains of a headache and
appears flushed. You note that he has not had any emesis and has not had any frank red blood in
his stool or melena (black tarry stools) over the past 5 hours. In response to your questions, J.G.
denies that he has an alcohol problem but later admits to drinking approximately a fifth of vodka
daily for the past 2 months. He reports that he was drinking vodka just before his admission to
the ED. He admits to having had seizures while withdrawing from alcohol in the past.

Admission Lab Work

Hgb 10.9 g/dL
Hct 23%
ALT (SGPT) 69 units/L
AST (SGOT) 111 units/L
GGT 75 units/L
Serum alcohol (ETOH) 291 mg/dL

1. Which data from your assessment of J.G. are of concern to you?

- His initial set of vitals (hypotension, tachypnea, fever, elevated pulse) may be indicative
of hypovolemic shock
- Pt is vomiting bright red blood which can be a sign of upper GI bleeding
- Diaphoresis
- Anxiety
- Tremors
- Headache
- Flushed appearance

2. What do the admission laboratory results indicate?

- The loss of blood is noted in the low levels of Hgb (normal: 13.5-17.5) and Hct (41%-
50%)
- Enzymes ALT (normal: 29-33) & AST (normal: 5-40) are elevated which indicate
abnormal liver function possibly cirrhosis
- ETOH levels are elevated (normal: 0-50 mg/dL) anything greater than 300 can lead to
respiratory depression. This indicates chronic alcoholism.

3. Which of the previous lab results specifically reflects chronic alcohol ingestion?
- Elevated ETOH levels and elevated liver enzymes

4. What are two most likely causes of J.G.'s symptoms?

- Hypovolemic shock

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 - Hemorrhagic gastritis

5. What is the most likely time frame for someone to have withdrawal symptoms after abrupt
cessation of alcohol?
- As early as 2 hrs after the last drink. Symptoms usually peak within 24-48 hrs
CASE STUDY PROGRESS
You note that J.G.'s physician has not diagnosed J.G. as having alcohol dependence, and his
orders do not include treatment for alcohol withdrawal.

6. As an RN, what action is necessary before you continue to care for J.G.?
- I would consult with the physician because the pt should be diagnosed with an alcohol
disorder. Talk to him about maybe why he drinks and inform him of the treatment options
there are. Also let him know his vitals and labs

7. According to the DSM-IV-TR, what is the difference between alcohol dependence and
alcohol abuse?

Alcohol Dependence
- Alcohol dependence is defined by the DSM-IV-TR as:
A maladaptive pattern of alcohol use, leading to clinically significant impairment or
distress, as manifested by three or more of the following seven criteria, occurring at any
time in the same 12-month period:
1. Tolerance
2. Withdrawal
3. Alcohol is often taken in larger amounts or over a longer period than was intended.
4. There is a persistent desire or there are unsuccessful efforts to cut down or control
alcohol use.
5. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or
recover from its effects.
6. Important social, occupational, or recreational activities are given up or reduced
because of alcohol use.
7. The individual continues to use alcohol despite knowing that they suffer from a
persistent or recurrent physical or psychological problem that is likely to have been
caused or exacerbated by drinking alcohol.

Alcohol Abuse
- Alcohol abuse is defined by the DSM-IV-TR as: A maladaptive pattern of alcohol abuse
leading to clinically significant impairment or distress, as manifested by one or more of
the following, occurring within a 12-month period:
- Recurrent alcohol use resulting in failure to fulfil major role obligations at work, school,
or home (e.g., repeated absences or poor work performance related to substance use;
substance-related absences, suspensions or expulsions from school; or neglect of children
or household).
- Recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an
automobile or operating a machine).

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 - Recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly
conduct).
- Continued alcohol use despite persistent or recurrent social or interpersonal problems
caused or exacerbated by the effects of the alcohol (e.g., arguments with spouse about
consequences of intoxication or physical fights).

8. What would be helpful for J.G.'s physician to know regarding J.G.'s substance abuse history?
- How much alcohol he drinks, what it is he drinks, and how frequent he drinks it. The fact that
when he withdraws he has seizures and his labs are starting to show signs of liver damage.
CASE STUDY PROGRESS
J.G.'s physician comes to the ICU to assess J.G. and tells you to “watch out” because J.G. is
about to go into alcohol withdrawal delirium. The physician writes several medication orders.

9. What medications are commonly prescribed for patients withdrawing from alcohol? (Select
all that apply.)
a. Benzodiazepines, such as chlordiazepoxide (Librium)
b. Naltrexone (Revia), an opioid-reversal agent
c. Acamprosate (Campral), an alcohol deterrent agent
d. Clonidine (Catapres), an alpha-adrenergic blocker
e. Antiepileptic drugs, such as carbamazepine (Tegretol)
f. Disulfiram (Antabuse), an alcohol deterrent agent
g. Atenolol (Tenormin), a beta-adrenergic blocker

10. Explain the rationale for each of the drugs used during acute alcohol withdrawal.
- chlordiazepoxide (Librium), reduces withdrawal symptoms, calms the vitals, and prevent
seizures
- Naltrexone is used to suppress cravings and the pleasurable effects of alcohol.
- Acomprosate is used to decrease the unpleasant effects of withdrawal (anxiety, restlessness, and
dysphoria)
- Clonidine is used for decreasing blood pressure and heart rate.
- Carbamazepine is used for decreasing risk of seizures.
- Disulfiram helps reduce craving by discouraging the consumption of alcohol.

11. What chronic health problems are associated with alcoholism? Use the following as a guide
•Peripheral neuropathy and Alcoholic myopathy due to a direct deficiency in B vitamins
•Wernicke’s encephalopathy due to thiamine deficiency
•Korsakoff’s psychosis identified by a syndrome of confusion, loss of recent memory and
confabulation and is frequently related to Wernicke’s encephalopathy
•Cardiomyopathy due to the accumulation of lipids in the heart thus enlarging and weakening the
heart and relate to CHF and arrhythmia
•Esophagitis because of the toxic effects on the esophageal mucosa
•Gastritis because the alcohol breaks down the stomach’s protective mucosal barrier allowing
hydrochloric acid to erode the stomach wall

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 •Pancreatitis and hepatitis, Cirrhosis of the liver, leukopenia, thrombocytopenia, sexual
dysfunction and fetal alcohol syndrome affecting a fetus if the mother ingests alcohol during the
pregnancy

12. What lab tests might the physician order to assess for nutritional deficiencies or other
medical problems J.G. is experiencing?
- •A serum glucose or finger-stick glucose test is indicated. Patients susceptible to
hypoglycemia. Patients in alcohol withdrawal develop anxiety, agitation, tremor, seizure,
and diaphoresis, all of which can occur with hypoglycemia.
- •A complete blood cell count (CBC) Long-term alcohol ingestion leads to
myelosuppression with a slight reduction in all cell lines; thrombocytopenia, Blood loss
from the GI tract and nutritional deficiencies produce anemia in alcohol withdrawal,
Megaloblastic anemia is observed in patients with alcoholism and based on a dietary
deficiency of vitamin B-12 and folate
- •A comprehensive metabolic panel is indicated to look for acidosis, dehydration,
concurrent renal disease, and other abnormalities that can occur in patients with chronic
alcoholism. Other findings may include A low BUN value is expected in alcoholic liver
disease. Obtain lipase levels if pancreatitis is suspected. Obtain the blood ammonia level
if hepatic encephalopathy is suspected.
- •Determination of magnesium and calcium levels and liver function tests (LFTs) may be
indicated because patients with chronic alcoholism usually have dietary magnesium
deficiency and possibly concurrent alcoholic hepatitis. Alcoholic pancreatitis may cause.
- Urinalysis is indicated, Measurement of prothrombin time may be indicated because
patients with cirrhosis are at risk for coagulopathy. PT should be considered in a patient
with active bleeding, Toxicology screening may be indicated.
PROGRESS
J.G. experiences alcohol withdrawal delirium that lasts for 36 hours before subsiding. He did not
experience
any seizures this time. As his medical condition stabilizes, he is transferred out of the ICU to the
hospital's psychiatric unit. He tells you that he is “ready to go home” and does not want to “touch
another
drink” but admits that he needs help.

13. What medications might be prescribed to J.G. to assist him with sobriety? What is the usual
treatment regimen, and what side effects and precautions should you educate the patient
about concerning each?
- Topiramate (Topamax) – helps treat alcohol dependence. Side effects include anxiety,
ataxia, confusion, diarrhea, diplopia, dizziness, drowsiness, dysphagia, fatigue, lack of
concentration, memory impairment, nausea, and nervousness. Drink plenty of fluid to
prevent kidney stones
- Naltrexone (ReVia, Vivitrol) - interferes with the pleasure obtained from consuming
alcohol. Side effects include abdominal or stomach cramping/pain, anxiety, nervousness,
restlessness or trouble sleeping, headache, joint or muscle pain, and unusual tiredness.
Patient must be free from opiates 7-10 days before starting this medication.
- Acamprosate (Campral) – reduces craving for alcohol. Side effects include extreme
feelings of sadness or emptiness, fear, and severe depression. If relapse occurs, the patient

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 should be instructed to continue the medication. This medication should be started
immediately after alcohol detox has taken place and there has been no alcohol
consumption for 7 days
- Disulfiram (Antabuse) – causes upset stomach if person consumes alcohol while taking
this drug. Side effects include drowsiness, sexual dysfunction, headache, metallic or
garlic taste in mouth, rash, unusual tiredness. Reactions can occur if taken while
consuming alcohol or up to 14 days after the last drink

14. What types of education and referral will be done before J.G.'s discharge from the hospital?
- Education includes: teaching about S/S of withdrawal, Triggers for substance abuse, Healthy
coping skills and stress management, Importance of maintaining medication regimen and going
to appointments, Information about other chronic diseases that alcohol contributes to
- J.G. can be referred to a Support group, AA group for the 12-step program, Group
psychotherapy, Individual therapy – cognitive behavioral therapy, aversion therapy,
psychotherapy, Family therapy

15. J.G. is referred to the local Alcoholics Anonymous (AA) program. What strategy can be
implemented to increase his likelihood of attendance to these meetings?
Make sure that J.G. finds a sponsor before discharge
Have J.G. keep a journal
Motivational interviewing, which can promote a patient’s desire to change
Collaboration with patient to set goals that they want to achieve
If J.G. has a sponsor and supportive environment, he is more likely to stay clean
CASE STUDY OUTCOME
J.G.'s AA sponsor meets with him while J.G. was still in the hospital, and the meeting went well.
The day after his discharge from the hospital, J.G. attends his first AA meeting with his sponsor.

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