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Difficulty: EasySubstance-Related and Addictive Disorders

A 45-year-old man is evaluated in the hospital on postoperative day 2 following an open reduction and internal fixation of a fractured tibia. The nursing staff reports that he has become increasingly agitated, confused, and restless over the past 4 hours. He is sweating profusely and frantically points to the corner of the room, claiming that spiders are crawling on the walls. His temperature is 38.3°C (100.9°F), blood pressure is 165/100 mmHg, pulse is 118/min, and respiratory rate is 20/min. Physical examination reveals a coarse, bilateral resting tremor in his hands. When contacted, the patient's husband reports that the patient typically drinks half a bottle of whiskey every evening but has not consumed any alcohol since his hospital admission. Which of the following is the most appropriate next step in management?

  1. Administer intravenous lorazepamAnswer
  2. B
    Obtain blood cultures and start broad-spectrum antibiotics
  3. C
    Administer intramuscular haloperidol
  4. D
    Consult psychiatry for management of a brief psychotic disorder
  5. E
    Remove the surgical dressings and probe the incision site for infection

Answer

Administer intravenous lorazepam
This patient's clinical presentation—agitation, confusion, visual hallucinations, coarse resting tremor, and severe autonomic instability (fever, tachycardia, hypertension)—occurring approximately 48 hours after his last drink is the classic presentation of delirium tremens (DTs). DTs is the most severe manifestation of alcohol withdrawal and carries a significant mortality rate if left untreated. The pathophysiology involves a sudden lack of GABAergic inhibition and a surge in excitatory glutamatergic activity. The appropriate next step in management is the administration of a benzodiazepine, such as intravenous lorazepam, diazepam, or chlordiazepoxide. Benzodiazepines substitute for the absent alcohol by stimulating GABA receptors, thereby reducing autonomic hyperactivity, controlling agitation, and preventing progression to withdrawal seizures.

Step-by-Step Solution

1
Analyze the patient's timeline and vital signs.
The patient is roughly 48 hours out from his last drink (postoperative day 2). He is exhibiting severe autonomic instability (fever, hypertension, tachycardia).
Timing and vital signs differentiate the stages of alcohol withdrawal.
2
Identify the specific clinical syndrome based on the physical exam and history.
The combination of autonomic hyperactivity, coarse tremors, visual hallucinations, and altered mental status in the context of abrupt alcohol cessation indicates delirium tremens.
Delirium tremens is a life-threatening medical emergency requiring immediate pharmacological intervention.
3
Select the most appropriate pharmacotherapy.
Intravenous benzodiazepines (like lorazepam) are the standard of care.
Benzodiazepines enhance GABA-A receptor activity, which suppresses the rebound excitatory central nervous system activity caused by sudden alcohol cessation.

Key Concept

Management of severe acute alcohol withdrawal (Delirium Tremens)
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Topics

Substance-Related and Addictive Disorders

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