A 35-year-old man who underwent emergency cholecystectomy a day ago begins having seizures. The surgery was uneventful, but since then, the patient has gradually become restless. His medical history is remarkable for gastritis and a period of heroin abuse in his 20s. The patient lives alone. Medications include omeprazole. Temperature is 37.2 C (99 F), blood pressure is 145/92 mm Hg, pulse is 114/min, and respirations are 18/min. Examination shows diaphoresis and tremors. Wound incisions show no evidence of inflammation, and biliary drainage appears adequate. Laboratory results are as follows: Which of the following is the most appropriate immediate treatment for this patient?

Question

A 35-year-old man who underwent emergency cholecystectomy a day ago begins having seizures.  The surgery was uneventful, but since then, the patient has gradually become restless.  His medical history is remarkable for gastritis and a period of heroin abuse in his 20s.  The patient lives alone.  Medications include omeprazole.  Temperature is 37.2 C (99 F), blood pressure is 145/92 mm Hg, pulse is 114/min, and respirations are 18/min.  Examination shows diaphoresis and tremors.  Wound incisions show no evidence of inflammation, and biliary drainage appears adequate.  Laboratory results are as follows:  Which of the following is the most appropriate immediate treatment for this patient?

Quizplus · Accepted Answer

11ec25c8_d88a_1e67_bc81_73922ad79b7a_MD0003_00 Unreported or underreported alcohol use is not uncommon in patients who have been admitted to the hospital for other treatments. This patient's seizures, diaphoresis, tremulousness, and elevated pulse and blood pressure a day after hospitalization and in the setting of a 2:1 aspartate aminotransferase/alanine aminotransferase ratio are consistent with alcohol withdrawal, for which benzodiazepines are the treatment of choice. The patient's inflammatory and synthetic liver dysfunction (transaminase elevation and prolonged PT, respectively) must be considered when selecting a benzodiazepine. Benzodiazepines that lack active metabolites and undergo hepatic metabolism via phase II glucuronidation instead of phase I cytochrome P450 oxidation are preferred in patients with evidence of liver dysfunction. Oxazepam, temazepam, and lorazepam fulfill these criteria. Lorazepam, an intermediate-duration benzodiazepine that can be given intravenously, is frequently preferred in hospitals. By contrast, chlordiazepoxide and diazepam are long-duration benzodiazepines that are metabolized via phase 1 cytochrome P450 oxidation into active metabolites and would confer serious risk of toxic accumulation in patients such as this one with liver dysfunction (Choices B and C). intermediate-duration benzodiazepine (Choices A and F) The partial opioid agonist buprenorphine and the full opioid agonist methadone can both be used in the treatment of opioid withdrawal. However, this patient's seizures and overall clinical presentation are consistent with alcohol withdrawal, and he does not exhibit signs and symptoms of opioid withdrawal (eg, mydriasis, piloerection, myalgias, vomiting, diarrhea, abdominal cramps, rhinorrhea, lacrimation). (Choice D) Gabapentin is a GABA analog that is not used as a first-line treatment for alcohol withdrawal. (Choice G) Valproate is an anticonvulsant that has not demonstrated efficacy in treating alcohol withdrawal or withdrawal-related seizures. Furthermore, it carries a risk of hepatotoxicity and would be relatively contraindicated in this patient. Educational objective: Benzodiazepines are the treatment of choice for alcohol withdrawal. If a patient has significant liver disease, lorazepam is the preferred agent due to its intermediate half-life, lack of active metabolites, and availability in intravenous form. References: The emergency medicine management of severe alcohol withdrawal. (http://www.ncbi.nlm.nih.gov/pubmed/28188055) Efficacy and safety of pharmacological interventions for the treatment of the alcohol withdrawal syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21678378)

A 35-Year-Old Man Who Underwent Emergency Cholecystectomy a Day Ago