A 52-year-old man is brought to the emergency department by emergency medical services aft… — USMLE Step 2 CK

A $52$ -year-old man is brought to the emergency department by emergency medical services after being found somnolent in a park. He has a documented history of severe alcohol use disorder and has been unhoused for the past year. On initial evaluation, he is lethargic but easily rousable. Vital signs reveal a temperature of $35.8^\circ\text{C}$ ( $96.4^\circ\text{F}$ ), blood pressure of $105/60\text{ mmHg}$ , pulse of $112/\text{min}$ , and respiratory rate of $14/\text{min}$ . A point-of-care blood glucose level is $52\text{ mg/dL}$ . Over the next hour, he becomes increasingly awake but is agitated, profoundly diaphoretic, and exhibits bilateral action tremors of his hands. Arrange the following clinical interventions in the most appropriate sequential order for the comprehensive management of this patient, from initial emergency presentation through hospital discharge.

1Assessment of airway patency, breathing, and circulation
2Administration of intravenous thiamine
3Administration of intravenous dextrose
4Administration of symptom-triggered intravenous lorazepam
5Prescription of oral naltrexone and referral to addiction counseling

Answer

The optimal clinical sequence is: Assessment of airway patency, breathing, and circulation → Administration of intravenous thiamine → Administration of intravenous dextrose → Administration of symptom-triggered intravenous lorazepam → Prescription of oral naltrexone and referral to addiction counseling.

The correct sequence ensures patient safety by prioritizing immediate life threats and preventing iatrogenic harm. The airway is always assessed first. Hypoglycemia must be corrected next, but because glucose metabolism rapidly depletes thiamine, thiamine must be given first or concurrently to prevent Wernicke encephalopathy. Acute withdrawal symptoms (tremors, agitation) are treated next with benzodiazepines to prevent seizures. Finally, long-term outpatient management with naltrexone is planned prior to discharge.

Step-by-Step Solution

Perform primary survey (ABCs).

Ensures the patient is protecting his airway and maintains adequate perfusion.

Any patient presenting with an altered level of consciousness requires immediate assessment of basic life-sustaining functions before diagnostic or secondary therapeutic interventions.

Administer intravenous thiamine.

Replenishes a critical coenzyme required for carbohydrate metabolism.

In individuals with severe alcohol use disorder, malnutrition frequently causes thiamine deficiency. Thiamine must be given prior to or alongside glucose to prevent precipitating Wernicke encephalopathy.

Administer intravenous dextrose.

Rapidly corrects the documented hypoglycemia (

52\text{ mg/dL}

Hypoglycemia is a life-threatening metabolic derangement that must be corrected immediately after securing the airway and providing thiamine.

Initiate symptom-triggered benzodiazepines (e.g., lorazepam).

Controls emergent agitation, diaphoresis, and tremors.

As the patient awakens, he exhibits classic signs of early alcohol withdrawal. Benzodiazepines suppress the hyperactive central nervous system, preventing withdrawal seizures and delirium tremens.

Prescribe maintenance pharmacotherapy and counseling.

Reduces alcohol cravings and supports long-term abstinence.

Once the acute life-threats and withdrawal phases are resolved, comprehensive discharge planning using medications like naltrexone and behavioral therapy is the standard of care for substance use disorders.

Key Concept

The management of patients with severe alcohol use disorder presenting with altered mental status requires a strict sequence: initial ABC stabilization, administration of thiamine prior to or with dextrose to prevent Wernicke encephalopathy, symptom-triggered benzodiazepines for withdrawal, and finally, maintenance pharmacotherapy for relapse prevention.

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