Emergency Department Case Study B (1)

Outline (from N Miles, NSCCAHS 2002)

 Mr Walker, a 67 year old retired banker, is BIBA after falling at a club
while intoxicated

 On arrival he is hypertensive, agitated, confused and poorly orientated

 He smells strongly of alcohol and is very disinhibited, speaks loudly, is

irrational and becomes hostile but apologises quickly

 He is disturbing other patients, and he is taken into a single cubical when

he slips, breaking his ulna and radius

 He is given morphine for pain and is dehydrated

 At 3am he is trying to climb out of bed and is confused

 Emergency Department Case Study B (2)
Questions – in small or large group(s)
1. What Triage category would you put this person in
– on arrival
– after the fall
– at 3am

2. What are the different diagnoses

3. What strategies could you use with Mr Walker to manage his behaviour
 Emergency Department Case Study A (3)
4. What are the signs of Wernicke’s Encephalopathy, it this what Mr Walker
is suffering from at 3.00am?

5. How would you know he is going from intoxication to withdrawal symptoms?

6. Where could you find information or advice on how to manage this situation?
 Emergency Department Case Study B (4)
Brief guide to answers for the questions
This case study is best conducted with an Emergency Department (ED)
nurse, preferably an CNS, CNE/CNC

1-2. These should be facilitated by the ED nurse

3. Approach in a calm manner, provide a quiet environment, reassure frequently,

explain interventions, do not challenge or threaten patient, be aware of Zero
Tolerance policies (refer to Guidelines Chapter 6 and 9.1 re: managing
intoxication and alcohol intoxication)

4. Opthalmoplegia (reduced eye movement or nystagmus), ataxia & confusion

– this diagnosis is possible – refer to Guidelines Chapter 9.1
 Emergency Department Case Study B (4)
Brief guide to answers for the questions
This case study is best conducted with an Emergency Department (ED)
nurse, preferably an CNS, CNE/CNC

5. It can be difficult to assess: use alcohol withdrawal scales, look for objective signs
of withdrawal, tremor & sweating, seek advice from specialist staff – withdrawal
can commence prior to a blood alcohol level of 0 (refer to Guidelines Chapter 6 and 9.1)
6. Contact local D&A services – the Specialist Advisory Service 1800 023 687 24hr
refer to NSW Drug and Alcohol Withdrawal Clinical Practice Guidelines NSW Health 2007
http://www.health.nsw.gov.au/policies/gl/2008/GL2008_011.html