Alcohol Withdrawal Delirium and a Request to Leave
A 46-year-old man was admitted 36 hours ago for IV antibiotics for cellulitis of the left leg. He has a 15-year history of heavy alcohol use, about one-fifth of vodka daily, and his last drink was 8 hours before admission. He now has a coarse tremor, is diaphoretic, with heart rate 118/min and blood pressure 158/96 mmHg, temperature 37.9 °C. He is picking at the air and says he sees "bugs on the wall." He is oriented to person only. His CIWA-Ar score is 18. He wants to leave because "the nurses are poisoning me." No family is present, and no legal hold has been initiated. The cellulitis is improving; WBC is 11,200/mm³.
1. What is the most likely cause of his agitation and hallucinations, and what findings argue for and against each alternative?
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The most likely cause is alcohol withdrawal delirium. He is roughly 44 hours from his last drink, which places him in the window for withdrawal delirium; withdrawal hallucinations and seizures typically appear earlier and delirium later. The autonomic hyperactivity (tremor, diaphoresis, heart rate 118, blood pressure 158/96) with disorientation and formed visual hallucinations is the classic triad.
Alternatives to rule out: sepsis or delirium from the cellulitis - against it are the improving leg, a near-normal white count, and a temperature of only 37.9 °C, though it cannot be excluded and should be checked. Hepatic encephalopathy - possible, but expect asterixis, a history of liver disease, and elevated ammonia; the tremor here is coarse rather than flapping. Hypoglycemia - must be checked immediately, because it is reversible and lethal. Wernicke encephalopathy or thiamine deficiency - nystagmus, ataxia, and confusion; give thiamine empirically. Withdrawal from benzodiazepines or other sedatives - ask about the history.
The safest reasoning is not to pick one diagnosis and stop but to treat withdrawal presumptively and simultaneously rule out hypoglycemia and infection.
2. Can he leave against medical advice? Describe the capacity assessment you would perform and what you would document.
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Legally, a patient with capacity may refuse treatment; a patient without capacity may not. Assess the four elements: can he communicate a choice, understand the relevant information (that the cellulitis still requires antibiotics and that untreated withdrawal can be fatal), appreciate the consequences of his choice, and reason with the information.
He can state a choice, but his stated reason - the delusional belief that staff are poisoning him - shows he cannot appreciate the consequences and is not reasoning from reality. That is an incapacity finding, not a stubbornness finding.
Document the specific questions asked and his specific answers, the CIWA score, and the lack of a legal hold at the time. Then call the provider immediately, request an emergency hold under state law or facility policy, notify the appropriate person or next of kin, and provide continuous observation until the hold is arranged. Do not document "left AMA" unless a genuine capacity evaluation has been done and the patient has been allowed to leave. Safety comes before paperwork.
3. Prioritize your nursing and pharmacologic interventions for the next 2 hours, including what you would avoid.
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Safety first: place him on continuous observation in a low-stimulation room, remove hazards, pad the side rails, institute fall and seizure precautions, and have suction and oxygen available. Attempt verbal de-escalation and reorientation; physical restraints only as a last resort, with an order, time limits, and monitoring.
Then stabilize physiology: check the blood glucose and give thiamine before or with dextrose (glucose without thiamine can precipitate Wernicke encephalopathy); give IV fluids for volume depletion; monitor vital signs at least hourly; and check electrolytes, magnesium, and liver function.
Then treat withdrawal: benzodiazepines are first-line and should be dosed by protocol against the CIWA score, with reassessment after each dose. Escalate to the provider if the score rises or if he seizes.
What to avoid: do not use antipsychotics alone to treat withdrawal - they lower the seizure threshold and do not address the autonomic instability; do not withhold benzodiazepines because of a liver history without discussing dose adjustment with the provider; and do not treat his request to leave as simply noncompliant behavior. The order of these interventions - safety, thiamine and glucose, benzodiazepine, monitoring - reflects the reversibility and lethality of each threat.