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Difficulty: MediumSubstance-Related and Addictive Disorders

A 54-year-old man is evaluated on postoperative day 2 following an emergency exploratory laparotomy for a perforated duodenal ulcer. Over the past 6 hours, the nursing staff reports that he has become highly agitated, disoriented, and profusely diaphoretic. He is currently shouting at the staff, claiming that there are "swarms of insects" crawling on the walls and his bedsheets. Medical records show no prior psychiatric history. Upon interview, his wife mentions that he typically drinks a pint of whiskey daily but has not consumed any alcohol since the morning of his admission. His temperature is 38.6°C (101.5°F), blood pressure is 168/104 mm Hg, pulse is 126/min, and respirations are 24/min. Physical examination reveals an oriented to person only, restless patient with a coarse, rhythmic tremor of the outstretched hands. The surgical abdomen is tender but without rebound, and the incision site is clean and intact. Which of the following is the most appropriate next step in management?

  1. Administer intravenous lorazepamAnswer
  2. B
    Administer intravenous haloperidol
  3. C
    Administer intravenous piperacillin-tazobactam
  4. D
    Administer intravenous phenytoin
  5. E
    Administer oral naltrexone

Answer

Administer intravenous lorazepam
The correct answer is to administer intravenous lorazepam. This patient is presenting with delirium tremens (DTs), the most severe manifestation of alcohol withdrawal, which typically occurs 48 to 96 hours after the last drink. Chronic alcohol consumption causes a compensatory downregulation of inhibitory GABA receptors and an upregulation of excitatory NMDA (glutamate) receptors. When alcohol is abruptly discontinued, this leads to unopposed central nervous system excitation. This excitation manifests clinically as profound autonomic instability (fever, tachycardia, hypertension), altered sensorium, visual or tactile hallucinations, and severe tremors. Benzodiazepines, such as lorazepam, are the first-line treatment. They act by stimulating GABA-A receptors, effectively replacing the inhibitory effect of alcohol, which mitigates autonomic hyperactivity, controls agitation, and prevents the development of withdrawal seizures. Lorazepam, along with oxazepam and temazepam, is often preferred in patients with potential underlying hepatic impairment because it undergoes simple phase II glucuronidation rather than complex phase I oxidative metabolism in the liver.

Step-by-Step Solution

1
Analyze the patient's timeline and history.
The patient has a history of heavy daily alcohol consumption and abruptly stopped approximately 48 hours ago due to an emergency admission.
Establishing the timeline of last substance use is critical for predicting the onset and type of withdrawal syndrome.
2
Evaluate the clinical presentation and vital signs.
The patient exhibits severe agitation, visual hallucinations, a coarse tremor, and profound autonomic instability (fever, tachycardia, hypertension) starting on postoperative day 2.
These specific signs occurring 48 to 96 hours after alcohol cessation define delirium tremens (alcohol withdrawal delirium).
3
Determine the optimal pharmacologic intervention.
Intravenous lorazepam is selected as the next best step in management.
Benzodiazepines stimulate GABA-A receptors, which have been downregulated by chronic alcohol use, thereby controlling agitation, reversing autonomic hyperactivity, and preventing progression to seizures.

Key Concept

Management of Delirium Tremens in Alcohol Withdrawal
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Topics

Substance-Related and Addictive Disorders

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