A 52-year-old male from Delhi presents to the emergency department with tremor, diaphoresis, and agitation. He reports consuming 8–10 pegs of whisky daily for the past 15 years. His last drink was 18 hours ago. Vital signs: BP 148/92 mmHg, HR 110 bpm, RR 20/min, temperature 37.8°C. Blood glucose 110 mg/dL, serum sodium 138 mEq/L. He is oriented to person and place but not time. What is the most appropriate immediate pharmacological intervention?

Question

Accepted Answer

A. Lorazepam 2–4 mg IV, repeated every 5–10 minutes until seizure activity ceases or sedation achieved. ## Alcohol Withdrawal Syndrome: Acute Management

**Key Point:** This patient presents with moderate-to-severe alcohol withdrawal (tremor, autonomic hyperactivity, disorientation) within 18 hours of last drink — consistent with the **early withdrawal phase** (6–24 hours post-cessation). Benzodiazepines are the gold standard first-line agent.

### Clinical Presentation & Severity Assessment

| Feature | Mild | Moderate | Severe |
|---------|------|----------|--------|
| Tremor | Fine, hands only | Visible, whole body | Gross, interferes with function |
| Autonomic signs | Mild tachycardia, diaphoresis | HR >100, BP elevated, fever | HR >120, BP >160, hyperthermia |
| CNS | Alert, oriented | Disoriented, agitation | Hallucinations, seizures, delirium tremens |
| Management | Outpatient benzodiazepines | Inpatient IV benzodiazepines | ICU-level care, aggressive benzodiazepines |

This patient has **moderate-to-severe withdrawal** (disorientation, significant autonomic hyperactivity, elevated temperature).

### Why Benzodiazepines?

1. **GABA~A~ receptor agonism** — alcohol withdrawal causes CNS hyperexcitability due to loss of GABA-mediated inhibition; benzodiazepines restore GABAergic tone.
2. **Seizure prophylaxis** — benzodiazepines reduce the risk of withdrawal seizures (which occur in 5–15% of untreated moderate-to-severe withdrawal).
3. **Symptom control** — tremor, anxiety, autonomic instability all respond to benzodiazepines.
4. **Evidence-based** — lorazepam is preferred in acute settings due to rapid onset and no active metabolites (safer in liver disease).

**High-Yield:** Lorazepam dosing in acute withdrawal: **2–4 mg IV every 5–10 minutes** until seizure activity ceases or adequate sedation achieved (CIWA-Ar score <8–10 or clinical stability). Titration is essential — do not give a fixed dose.

### Why NOT the Other Options?

**Thiamine + Dextrose (Option B):** While thiamine is essential to prevent Wernicke encephalopathy and should be given, it is **not the immediate pharmacological intervention** for acute withdrawal symptoms. Thiamine is supportive; benzodiazepines are definitive. Dextrose without thiamine can precipitate Wernicke syndrome — always give thiamine first or concurrently.

**Haloperidol (Option C):** Antipsychotics have **no role in uncomplicated alcohol withdrawal**. They do not prevent seizures, do not address the underlying GABAergic deficit, and carry risk of QT prolongation and neuroleptic malignant syndrome. Haloperidol is reserved for alcohol hallucinosis (when benzodiazepines have controlled autonomic symptoms) or delirium tremens refractory to benzodiazepines.

**Phenytoin (Option D):** Phenytoin is **ineffective for alcohol withdrawal seizure prophylaxis** [cite:Harrison 21e Ch 474]. Alcohol withdrawal seizures are due to CNS hyperexcitability, not a primary seizure disorder; phenytoin does not address the GABAergic deficit. Benzodiazepines are the only agents proven to prevent withdrawal seizures.

### Clinical Pearl

**Warning:** This patient is disoriented — always give **thiamine 100 mg IV/IM BEFORE or WITH dextrose** to prevent acute Wernicke encephalopathy (triad: ophthalmoplegia, ataxia, confusion). However, thiamine is **not the answer to the acute withdrawal question** — benzodiazepines are the immediate pharmacological priority.

### Management Algorithm

```mermaid
flowchart TD
  A[Alcohol withdrawal suspected]:::outcome --> B{Severity?}:::decision
  B -->|Mild: tremor, no autonomic signs| C[Outpatient benzodiazepines + thiamine]:::action
  B -->|Moderate: autonomic hyperactivity, disorientation| D[Inpatient IV lorazepam 2-4 mg Q5-10min]:::action
  B -->|Severe: seizures, hallucinations, delirium| E[ICU admission, aggressive IV lorazepam]:::urgent
  D --> F[Thiamine 100 mg IV]:::action
  E --> F
  D --> G[Monitor CIWA-Ar score]:::action
  E --> G
  G --> H{Seizure risk?}:::decision
  H -->|Yes| I[Benzodiazepines prevent seizures]:::action
  H -->|No| J[Continue supportive care]:::action
```

Answer

B. Phenytoin 15–20 mg/kg IV loading dose for seizure prophylaxis

Answer

C. Haloperidol 5 mg IM for agitation and disorientation

Answer

D. Thiamine 100 mg IV followed by dextrose 50 mL of 50% solution

Explanation

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