HPI
- A 53-year-old male with a history of chronic daily alcohol use presents to the ED via EMS after a witnessed seizure at home
- The medics say he drinks every day, but his last drink was 3 days ago because he was not able to go to the store (history obtained from the sister who witnessed the seizure)
Physical Examination
T 98.3F, BP 177/106, HR 191, RR 22, Sat 93%
- Patient appears anxious, uncomfortable, and is actively vomiting blood tinged sputum
- He appears confused and is not answering questions appropriately
- He is tachycardic and his lungs are clear to auscultation bilaterally
- Abd: soft NTND
Differential
- Alcohol withdrawal/ Delirium Tremens
- Thyrotoxicosis
- Sepsis
- Pulmonary embolism
- Heart failure
Workup and Management
- The nurse informs you that the patient is seizing
- This patient is exhibiting evidence of delirium tremens (psychomotor agitation and autonomic instability) and alcohol withdrawal seizure
- The patient is no longer tolerating his secretions, he is confused, gurgling, and requires a definitive airway
- After intubation, you bolus the patient with propofol and start him a propofol infusion
- The patient is admitted to the ICU for further management
Teaching Points
- ETOH withdrawal begins 6-8 hours after last intake and peaks in 72 hours
- Symptom based treatment via the CIWA score can help stratify patients, scores >15 indicate severe withdrawal
- Start with IV diazepam at 10mg or lorazepam at 4mg and repeat them in doubling doses
- Consider adding phenobarbital for refractory cases (i.e. after 200 mg of diazepam)
- Consider propofol as the induction agent and sedative post-intubation as propofol potentiates GABA receptor activity and inhibits NMDA receptors Summary
- Delerium tremens can result in death from hyperthermia, arrhythmia and seizures
Sources:
Long D, Long B, Koyfman A. The emergency medicine management of severe alcohol withdrawal. The American Journal of Emergency Medicine. 2017;35(7):1005-1011. doi:10.1016/j.ajem.2017.02.002
Schuckit MA, Author Affiliations From the Department of Psychiatry. Recognition and Management of Withdrawal Delirium (Delirium Tremens): NEJM. New England Journal of Medicine. https://www.nejm.org/doi/10.1056/NEJMra1407298. Published February 5, 2015. Accessed December 9, 2020.
