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Difficulty: MediumPharmacologic Interventions

A 48-year-old man is brought to the emergency department by emergency medical services after being found wandering near a bus station. He is agitated, diaphoretic, and yelling at unseen individuals. He has a known history of severe alcohol use disorder and has been hospitalized multiple times for intoxication. Vital signs show a heart rate of 122/min, blood pressure of 168/100 mm Hg, respiratory rate of 20/min, and oxygen saturation of 97% on room air. Fingerstick blood glucose is 82 mg/dL. Physical examination reveals coarse, bilateral hand tremors, bilateral horizontal nystagmus, and a broad-based, unsteady gait. He is disoriented to place and time. Which of the following pharmacologic interventions are appropriate in the immediate management of this patient? (Select all that apply)

  1. A
    Intravenous flumazenil
  2. B
    Intravenous haloperidol
  3. Intravenous lorazepamAnswer
  4. D
    Intravenous phenytoin
  5. Intravenous thiamineAnswer

Answer

The correct interventions are intravenous lorazepam and intravenous thiamine.
The correct choices are intravenous lorazepam and intravenous thiamine. This patient presents with moderate-to-severe alcohol withdrawal, evidenced by autonomic hyperactivity (tachycardia, hypertension, diaphoresis), coarse tremors, and severe agitation. Benzodiazepines, such as lorazepam, are the first-line standard of care for alcohol withdrawal; they enhance GABA-A receptor activity, providing cross-tolerance to alcohol, which controls agitation and significantly reduces the risk of withdrawal seizures and delirium tremens. Furthermore, the patient exhibits the classic triad of Wernicke encephalopathy: encephalopathy (disorientation and agitation), oculomotor dysfunction (horizontal nystagmus), and gait ataxia. This condition is caused by severe thiamine (vitamin B1) deficiency, which is highly prevalent in severe alcohol use disorder. Intravenous thiamine must be administered immediately to reverse these symptoms and prevent the development of irreversible Korsakoff syndrome.

Step-by-Step Solution

1
Identify the patient's primary clinical syndrome based on history and physical exam findings.
The patient is exhibiting signs of acute alcohol withdrawal (tachycardia, hypertension, diaphoresis, tremors, agitation) and Wernicke encephalopathy (nystagmus, ataxia, altered mental status).
Accurate diagnosis of multiple overlapping syndromes dictates the immediate choice of pharmacotherapy and prevents the administration of contraindicated agents.
2
Select the appropriate initial pharmacologic therapy for alcohol withdrawal.
Intravenous lorazepam is chosen to control agitation, stabilize vital signs, and prevent withdrawal seizures.
Benzodiazepines provide essential cross-tolerance at the GABA-A receptor, safely mitigating the effects of abrupt alcohol cessation.
3
Select the appropriate targeted therapy for the patient's acute neurologic deficits.
Intravenous thiamine is selected to treat the triad of nystagmus, ataxia, and encephalopathy.
Chronic alcohol use leads to thiamine deficiency; prompt replenishment is required to reverse Wernicke encephalopathy and prevent irreversible Korsakoff syndrome.

Key Concept

The initial management of a patient presenting with simultaneous alcohol withdrawal and Wernicke encephalopathy requires prompt administration of benzodiazepines to prevent seizures and delirium tremens, alongside intravenous thiamine to prevent permanent neurologic damage.
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Pharmacologic Interventions

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