Question 2 of 18

A 63-year-old man brought to the emergency department by EMS confused, agitated, and tremulous. Rectal temperature 100.8°F, heart rate 125/min, respiratory rate 20/min, blood pressure 170/80 mm Hg, and pulse oximetry 96% on room air. He gives a history of ingesting six beers every day, but denies illicit drug use. You give him 2 mg of intravenous lorazepam, but there is no change in his symptoms. You should now give him:

Intravenous vitamin C.

Intravenous antibiotics.

Intramuscular haloperidol.

More intravenous lorazepam.

Oral charcoal.

This patient has delirium tremens (DTs) from alcohol withdrawal and needs to be treated aggressively with benzodiazepines such as lorazepam or diazepam to prevent further complications. Alcohol withdrawal begins as early as 6 hours after a decreased level of ethanol intake. Serum ethanol levels do not have to fall to zero before withdrawal begins: can begin with a decreased alcohol intake in a heavy drinker. The first stage of alcohol withdrawal is hallucinosis, manifested by hallucinations with an otherwise clear sensorium. Approximately 12 hours after cessation or decreased alcohol intake, the patient may have alcohol withdrawal seizures. Delirium tremens is the most serious complication of withdrawal and classically begins 48–96 hours later. It is characterized by autonomic instability and mental status changes. The treatment of DTs and withdrawal is administration of alcohol or benzodiazepines. Benzodiazepines are titrated to effect; ideally the patient should be sedated but breathing. Use persistent tachycardia and hypertension as indicators of inadequate treatment. In this patient, 2 mg of lorazepam are not enough. Case reports of patients given diazepam for DTs have reported the need for 1–2 g to achieve adequate treatment. Haloperidol should not be given to those in alcohol withdrawal as it may mask the symptoms leading to inadequate benzodiazepine administration. It is important to look for underlying sources of infection in patients with alcohol withdrawal. Alcoholics often stop drinking because they are too sick to drink. Infection, trauma, liver failure, GI bleeding, and other physiologic stressors can all precipitate DTs. A chest x-ray and antibiotics may be indicated in this patient, but he should be stabilized and treated for DTs prior to an extensive evaluation.