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Difficulty: HardSubstance-Related and Addictive Disorders

A 52-year-old man is evaluated on postoperative day 3 following an emergency exploratory laparotomy and repair of a perforated duodenal ulcer. The nursing staff reports that he has become increasingly combative over the last few hours. The patient is shouting that there are "swarms of insects" crawling on the walls of his room. He has no known psychiatric history. His medical history is significant for hypertension and a 20-pack-year smoking history. Social history is notable for drinking 6 to 8 beers daily, though he stated he was planning to quit while in the hospital. Vital signs are temperature 38.8°C (101.8°F), blood pressure 168/102 mmHg, pulse 122/min, and respirations 22/min. Physical examination reveals a diaphoretic, agitated man. Abdominal exam shows a clean, intact surgical incision with mild tenderness but no rebound or guarding. Neurologic examination shows a coarse, rhythmic tremor of the outstretched hands. Which of the following is the most appropriate next step in the management of this patient?

  1. Intravenous lorazepamAnswer
  2. B
    Intravenous haloperidol
  3. C
    Broad-spectrum antibiotics and blood cultures
  4. D
    Intravenous propranolol
  5. E
    Computed tomography scan of the head

Answer

Intravenous lorazepam
The correct intervention is the administration of a benzodiazepine. This patient is experiencing delirium tremens (DTs), the most severe form of alcohol withdrawal. DTs typically manifests 48 to 96 hours after the last drink and is characterized by a rapidly fluctuating sensorium (delirium), vivid hallucinations (often visual or tactile, such as seeing insects), severe autonomic hyperactivity (fever, tachycardia, hypertension, diaphoresis), and profound agitation. The pathophysiology involves a sudden lack of alcohol-induced GABAergic inhibition, leading to unopposed excitatory glutamatergic activity. Benzodiazepines, such as lorazepam, diazepam, or chlordiazepoxide, are the gold-standard first-line treatment. They enhance GABA-A receptor activity, thereby stabilizing the central nervous system, rapidly controlling agitation, and preventing withdrawal seizures. Intravenous administration is necessary for patients with severe symptoms to achieve rapid symptom control.

Step-by-Step Solution

1
Analyze the patient's presentation and timeline.
The patient is on postoperative day 3 (approximately 72 hours since admission/last alcohol intake) and presents with fever, tachycardia, hypertension, diaphoresis, severe agitation, and visual hallucinations.
Establishing the timeline of symptoms relative to alcohol cessation is critical for diagnosing alcohol withdrawal syndromes.
2
Formulate a diagnosis based on the symptom cluster.
The combination of delirium, visual hallucinations (formication), and severe autonomic hyperactivity 48-96 hours after alcohol cessation in a patient with a history of heavy daily alcohol use is the classic presentation of Delirium Tremens (DTs).
DTs is a life-threatening medical emergency that must be differentiated from primary psychiatric disorders and postoperative infections.
3
Select the most appropriate immediate intervention.
Intravenous benzodiazepines (such as lorazepam) are indicated to suppress central nervous system hyperactivity, control agitation, and prevent seizures.
Benzodiazepines enhance GABA-A receptor activity, effectively replacing the sudden absence of alcohol's inhibitory effects.

Key Concept

Diagnosis and management of Delirium Tremens (Severe Alcohol Withdrawal)
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Topics

Substance-Related and Addictive Disorders

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