A 50-year-old man is evaluated on the surgical ward on postoperative day 3 following an un… — USMLE Step 2 CK

A 50-year-old man is evaluated on the surgical ward on postoperative day 3 following an uncomplicated partial colectomy for recurrent diverticulitis. The cross-cover physician is called because the patient has become acutely disoriented, diaphoretic, and extremely agitated, stating that he sees spiders descending from the ceiling. Vital signs reveal a temperature of $38.5^\circ\mathrm{C}$ ( $101.3^\circ\mathrm{F}$ ), blood pressure of $172/106\text{ mmHg}$ , pulse of $128/\text{min}$ , and respiratory rate of $24/\text{min}$ . Physical examination shows a coarse tremor of the extended hands. His surgical dressings are clean and intact, and the abdomen is nondistended with mild expected incisional tenderness. A review of his preoperative social history indicates he consumes one pint of whiskey daily. Which of the following is the most appropriate next step in management?

Intravenous diazepamAnswer
B
Intravenous haloperidol
C
Intravenous piperacillin-tazobactam
D
Abdominal computed tomography
E
Intravenous metoprolol

Answer

The most appropriate next step in management is the administration of intravenous diazepam.

The patient is experiencing severe alcohol withdrawal, specifically delirium tremens, which typically begins 48 to 96 hours after the last drink. The hallmark features include autonomic instability (tachycardia, hypertension, fever), altered mental status, and visual hallucinations (often of insects or animals). Benzodiazepines, such as intravenous diazepam, are the gold standard treatment. They enhance the inhibitory effect of GABA, compensating for the sudden lack of alcohol and preventing progression to seizures and cardiovascular collapse.

Step-by-Step Solution

Analyze the patient's presentation and timeline.

The patient developed fever, tachycardia, hypertension, diaphoresis, severe agitation, hallucinations, and tremor 3 days after hospital admission.

Establishing the timeline helps narrow the differential diagnosis for postoperative fever and altered mental status.

Correlate symptoms with the patient's history.

The patient consumes a significant amount of alcohol daily, and his symptoms align perfectly with the 48-to-96-hour window typical for delirium tremens.

Identifying the underlying etiology prevents misdiagnosing the condition as a primary surgical complication or primary psychotic disorder.

Select the most appropriate pharmacotherapy.

Intravenous diazepam (or another benzodiazepine) is chosen.

Benzodiazepines stimulate GABA receptors, reversing the central nervous system hyperactivity caused by alcohol withdrawal and preventing progression to seizures.

Key Concept

The diagnosis of delirium tremens in a postoperative setting and its appropriate management with benzodiazepines.

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