Acute and critical care medicine for MRCPI Part 1

A 55-year-old man with a history of alcohol dependence is admitted after a fall. Thirty-six hours after admission he becomes agitated, tremulous and sweating, with a heart rate of 122 and visual hallucinations of insects on the wall. What is the most appropriate treatment?

1. Immediate resumption of alcohol under supervision Not standard practice. It is occasionally improvised but is not an evidence-based or safe management strategy.
2. Benzodiazepine according to a symptom-triggered regimen, plus parenteral thiamine correct Correct. This is alcohol withdrawal progressing towards delirium tremens. Benzodiazepines are the treatment, ideally symptom-triggered using a validated scale, and parenteral thiamine must be given before any glucose load to prevent Wernicke encephalopathy.
3. Intravenous glucose to correct any hypoglycaemia, then thiamine Wrong order, and this sequence causes harm. Glucose before thiamine in a thiamine-deficient patient can precipitate Wernicke encephalopathy. Thiamine first.
4. Clonidine alone to control the autonomic features Wrong. It blunts the autonomic signs, which masks worsening withdrawal without preventing seizures or delirium.
5. Haloperidol as first-line monotherapy Wrong as monotherapy. Antipsychotics lower the seizure threshold and do not treat the underlying GABA withdrawal. They are an adjunct for hallucinations that persist despite adequate benzodiazepine.

The point: Alcohol withdrawal timeline: tremor and anxiety at 6 to 12 hours, seizures at 12 to 48, delirium tremens at 48 to 72 with a real mortality. Symptom-triggered benzodiazepine dosing outperforms fixed schedules. Thiamine before glucose, always.

Source: NICE CG100 — Alcohol-use disorders: diagnosis and management of physical complications NICE · tier 1, national regulator or guidance