A 52-year-old male construction worker from Delhi presents to the emergency department with tremors, sweating, and agitation. He reports consuming 8–10 pegs of whisky daily for the past 15 years. His last drink was 18 hours ago. On examination, he is tremulous, tachycardic (HR 110/min), hypertensive (BP 158/96 mmHg), and has a temperature of 37.8°C. He is oriented to person and place but disoriented to time. Blood glucose is 110 mg/dL, and serum electrolytes are normal. What is the most appropriate immediate pharmacological intervention?

Explanation

## Clinical Diagnosis: Alcohol Withdrawal Syndrome ### Presentation Recognition The patient meets criteria for **early alcohol withdrawal** (tremor, autonomic hyperactivity within 6–24 hours of last drink) progressing toward **hallucinosis** (disorientation to time suggests altered cognition). The timeline, daily consumption, and vital sign abnormalities are classic. ### Immediate Management Approach **Key Point:** Benzodiazepines are the gold standard for acute alcohol withdrawal because they: - Reduce seizure risk (by 50–65%) - Prevent progression to delirium tremens - Control autonomic hyperactivity - Are the only class with proven mortality benefit in severe withdrawal **High-Yield:** Lorazepam is preferred over diazepam in this setting because: - Shorter half-life (12 hours vs. 48 hours) — easier titration and monitoring - No active metabolites — safer in hepatic impairment - Can be given IV, IM, or PO - Rapid onset (5–10 minutes IV) ### Thiamine Administration **Clinical Pearl:** Thiamine MUST be given before or concurrent with glucose-containing fluids to prevent Wernicke encephalopathy. In this case, thiamine 100 mg IV is indicated because: - Chronic alcohol impairs thiamine absorption and storage - Risk of precipitating Wernicke syndrome if dextrose is given without thiamine - Standard dose: 100 mg IV/IM daily for 3–5 days, then oral maintenance ### Correct Sequence 1. Secure airway/IV access 2. **Lorazepam 2 mg IV** (titrate q 5–10 min to calm, suppress tremor; max 0.1 mg/kg per dose) 3. **Thiamine 100 mg IV** (concurrent or immediately after) 4. Glucose if hypoglycemic (after thiamine) 5. Correct electrolytes (Mg²⁺, K⁺, PO₄³⁻) 6. Supportive care, monitoring for seizures/DTs ### Withdrawal Severity Assessment | Feature | Early Withdrawal | Hallucinosis | Withdrawal Seizure | Delirium Tremens | |---------|------------------|--------------|--------------------|-----------------| | **Onset** | 6–24 hrs | 12–48 hrs | 6–48 hrs | 48–96 hrs | | **Tremor** | ✓ | ✓ | ✓ | ✓ | | **Autonomic** | Mild–moderate | Moderate | Severe | Severe | | **Hallucinations** | No | Visual/tactile | No | Yes (visual, tactile, olfactory) | | **Seizures** | No | No | Yes | Possible | | **Disorientation** | No | Possible | No | Yes | | **Mortality (untreated)** | <5% | ~5% | ~5% | 15–20% | This patient's disorientation suggests early hallucinosis; benzodiazepines are critical to prevent progression to delirium tremens. **Mnemonic: CIWA-Ar** — Clinical Institute Withdrawal Assessment for Alcohol scale (revised). Scores ≥15 warrant benzodiazepine dosing; ≥20 indicates severe withdrawal requiring ICU monitoring.