A 42-year-old man is evaluated on the surgical ward due to severe agitation and confusion.… — USMLE Step 2 CK

A 42-year-old man is evaluated on the surgical ward due to severe agitation and confusion. He was admitted two days ago after sustaining a right femur fracture in a motor vehicle collision, for which he underwent an uncomplicated open reduction and internal fixation. His medical history is significant for a 15-year history of heavy daily alcohol consumption, but he has had no access to alcohol since his admission. His temperature is $38.3^\circ\text{C}$ ( $100.9^\circ\text{F}$ ), blood pressure is $168/102\text{ mmHg}$ , pulse is $124/\text{min}$ , and respirations are $22/\text{min}$ . On examination, the patient is profusely diaphoretic and tremulous. He is disoriented to time and place and repeatedly swats at the air, claiming that spiders are crawling down the walls. The surgical incision site is clean, dry, and intact. Which of the following is the most appropriate next step in the management of this patient?

Intravenous lorazepamAnswer
B
Intravenous haloperidol
C
Intravenous piperacillin-tazobactam
D
Computed tomography pulmonary angiography
E
Oral sertraline

Answer

Intravenous lorazepam

The correct answer is intravenous lorazepam. This patient is exhibiting classic signs of delirium tremens (DTs), a severe and potentially life-threatening form of alcohol withdrawal. DTs typically occurs 48 to 96 hours after the last drink. The hallmark features include profound altered mental status (confusion, disorientation), visual or tactile hallucinations (e.g., bugs crawling on walls, known as formication), and severe autonomic hyperactivity (tachycardia, hypertension, fever, and diaphoresis). The primary treatment for alcohol withdrawal is benzodiazepine therapy. Drugs like lorazepam, diazepam, or chlordiazepoxide enhance GABA-A receptor activity, which suppresses the rebound central nervous system excitation, thereby controlling agitation and preventing withdrawal seizures.

Step-by-Step Solution

Identify the patient's risk factors and timeline of symptom onset.

The patient has a long history of heavy alcohol use and abruptly stopped drinking 48 hours ago due to hospital admission.

Establishing the timeline of abstinence is critical for diagnosing substance withdrawal syndromes.

Analyze the clinical presentation.

The patient exhibits severe autonomic hyperactivity (tachycardia, hypertension, fever, diaphoresis), tremors, altered sensorium, and tactile/visual hallucinations (seeing/feeling spiders).

These specific signs point directly to delirium tremens (DTs), the most severe form of alcohol withdrawal.

Select the most appropriate initial therapy.

Intravenous lorazepam is selected to control the withdrawal symptoms.

Benzodiazepines replace the inhibitory tone of alcohol on GABA-A receptors, effectively treating agitation and significantly reducing the risk of fatal seizures.

Key Concept

Delirium tremens typically presents 48 to 96 hours after alcohol cessation with autonomic hyperactivity, altered mental status, and hallucinations; it is acutely managed with intravenous benzodiazepines.

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