A 36-year-old man is brought to the emergency department by his wife for treatment of severe restlessness. She says, "I told him he has to come in and get checked out. Last night, he didn't come home and was partying all night with friends. He finally admitted that he has been using drugs again and drinking for the past year without telling me." The patient is not forthcoming regarding the specific details of his drug and alcohol use. He feels depressed and suicidal with thoughts of hanging himself. He says, "I started using drugs again because it is the only thing that helps my depression." The patient's eating and sleeping have been erratic over the past month. In the emergency department, he feels "shaky" and has a headache and nausea but is cognitively intact. He has no other medical issues and does not use tobacco.
Temperature is 36.7 C (98 F), blood pressure is 168/85 mm Hg, and pulse is 110/min. The patient is restless and diaphoretic. Cardiopulmonary examination is normal. The abdomen is soft and nontender. He has visible tremors of both hands and muscle twitches in all 4 extremities. At the end of the examination, he exhibits mild truncal myoclonic jerks.
Complete blood count and serum chemistries are unremarkable. Liver function tests are pending. Blood alcohol level is 70 mg/dL. Urine toxicology screen is positive for marijuana and heroin but negative for cocaine and amphetamines.
Intravenous fluids and a security watch are initiated.
Which of the following is the most appropriate next step in management of this patient?

Question

A 36-year-old man is brought to the emergency department by his wife for treatment of severe restlessness.  She says, "I told him he has to come in and get checked out.  Last night, he didn't come home and was partying all night with friends.  He finally admitted that he has been using drugs again and drinking for the past year without telling me."  The patient is not forthcoming regarding the specific details of his drug and alcohol use.  He feels depressed and suicidal with thoughts of hanging himself.  He says, "I started using drugs again because it is the only thing that helps my depression."  The patient's eating and sleeping have been erratic over the past month.  In the emergency department, he feels "shaky" and has a headache and nausea but is cognitively intact.  He has no other medical issues and does not use tobacco.
Temperature is 36.7 C (98 F), blood pressure is 168/85 mm Hg, and pulse is 110/min.  The patient is restless and diaphoretic.  Cardiopulmonary examination is normal.  The abdomen is soft and nontender.  He has visible tremors of both hands and muscle twitches in all 4 extremities.  At the end of the examination, he exhibits mild truncal myoclonic jerks.
Complete blood count and serum chemistries are unremarkable.  Liver function tests are pending.  Blood alcohol level is 70 mg/dL.  Urine toxicology screen is positive for marijuana and heroin but negative for cocaine and amphetamines.
Intravenous fluids and a security watch are initiated.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient is exhibiting signs and symptoms of alcohol withdrawal, which is characterized by tremors, insomnia, restlessness, gastrointestinal upset, headache, diaphoresis, tachycardia, and hypertension. Symptoms can begin within hours of the last drink and, in alcohol-tolerant individuals, can occur even with a significant blood alcohol level. In more severe cases, the patient may progress to having seizures (for which muscle twitches-and possible myoclonic jerks, as seen in this patient-may be a prelude) and delirium tremens (DTs), characterized by tactile hallucinations, disorientation, and worsening of other withdrawal symptoms. Patients exhibiting worsening withdrawal symptoms require benzodiazepine administration to prevent progression of withdrawal and DTs. Lorazepam, which has a relatively short half-life and no metabolites, is usually preferred in the emergency setting and can be administered intravenously for rapid effect. Longer-acting benzodiazepines with active metabolites are generally not used in the acute setting due to the risks of oversedation in patients with liver disease. (Choice A) Although carbamazepine has been used in the treatment of mild alcohol withdrawal, there is less evidence for its efficacy in patients with severe withdrawal who are at risk for DTs. Alcohol withdrawal seizures are self-limited and do not require anticonvulsant therapy. (Choice B) Clonidine is used as a treatment for opioid withdrawal but has not been shown to prevent the development of alcohol withdrawal seizures or DTs. Although both alcohol and opioid withdrawal can present with vital sign abnormalities, this patient's significant hypertension and tachycardia are more likely due to alcohol withdrawal. In addition, he lacks characteristic features of opioid withdrawal (eg, mydriasis, yawning, increased bowel sounds, piloerection). (Choice C) Antipsychotics such as haloperidol are not indicated as these drugs lower the seizure threshold and would not treat the patient's alcohol withdrawal. (Choice E) Beta blockers can decrease heart rate and blood pressure. However, they would not treat the underlying condition or reduce the risk of seizures or DTs. In addition, their use is often problematic during alcohol withdrawal as they can mask some of the symptoms and lead to underestimation of withdrawal severity. Educational objective: Alcohol withdrawal syndrome may present with tremors, insomnia, restlessness, gastrointestinal upset, headache, diaphoresis, tachycardia, and hypertension, as well as generalized seizures and delirium tremens. In the emergency setting, lorazepam is the preferred agent for treatment of the emerging withdrawal syndrome. __________ References: Alcohol withdrawal syndrome: benzodiazepines and beyond. (http://www.ncbi.nlm.nih.gov/pubmed/26500991) Alcohol withdrawal syndrome: mechanisms, manifestations, and management. (http://www.ncbi.nlm.nih.gov/pubmed/27586815) The emergency medicine management of severe alcohol withdrawal. (http://www.ncbi.nlm.nih.gov/pubmed/28188055)

A 36-Year-Old Man Is Brought to the Emergency Department by His