A 54-year-old man with a severe alcohol use disorder is brought to the emergency department for severe confusion, tremulousness, and an unsteady gait. Initial vital signs reveal a heart rate of 115/min and a blood pressure of 160/95 mm Hg. Point-of-care blood glucose is 55 mg/dL. Neurologic examination shows prominent bilateral horizontal nystagmus and resting hand tremors.
Arrange the following clinical interventions in the most appropriate chronological sequence for managing this patient, from first to last.
- 1Evaluate airway, breathing, and circulation, and establish intravenous access
- 2Administer high-dose intravenous thiamine
- 3Administer intravenous dextrose
- 4Administer intravenous lorazepam using a symptom-triggered approach
- 5Initiate oral naltrexone and comprehensive psychosocial treatment
Cevap
The correct chronological sequence is: 1) Evaluate airway, breathing, and circulation, and establish intravenous access; 2) Administer high-dose intravenous thiamine; 3) Administer intravenous dextrose; 4) Administer intravenous lorazepam using a symptom-triggered approach; 5) Initiate oral naltrexone and comprehensive psychosocial treatment.
The correct sequential management of a patient presenting with severe alcohol withdrawal complicated by hypoglycemia and classic signs of Wernicke encephalopathy (ataxia, confusion, nystagmus) follows a strict physiological priority. First, always secure airway, breathing, circulation, and establish IV access. Second, thiamine must be administered BEFORE glucose; glucose metabolism relies on thiamine-dependent enzymes. Administering dextrose without prior thiamine abruptly depletes any remaining thiamine, precipitating irreversible Korsakoff syndrome. Third, dextrose is given to correct the documented hypoglycemia. Fourth, intravenous lorazepam is administered via a symptom-triggered protocol to manage the acute hyperadrenergic withdrawal state. Finally, long-term relapse prevention therapies, such as naltrexone, are initiated only after the patient is completely detoxified and medically stable.
Adım Adım Çözüm
Anahtar Kavram
In patients with alcohol use disorder and suspected Wernicke encephalopathy, intravenous thiamine must always be administered before or concurrently with intravenous dextrose to prevent irreversible Korsakoff syndrome.