A 42-year-old male construction worker from Delhi presents to the emergency department with tremors, 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: HR 110 bpm, BP 148/92 mmHg, temperature 37.8°C. Neurological exam reveals coarse tremor of the hands, hyperreflexia, and mild confusion. Blood glucose is 110 mg/dL, serum electrolytes are normal. What is the most appropriate immediate pharmacological management?

Explanation

## Clinical Diagnosis: Alcohol Withdrawal Syndrome This patient presents with classic early-to-intermediate alcohol withdrawal (tremulousness, autonomic hyperactivity, confusion) occurring 18 hours after cessation of heavy chronic alcohol use. ### Key Clinical Features | Feature | Finding | Significance | |---------|---------|---------------| | Timeline | 18 hours post-cessation | Early withdrawal (6–24 hrs) | | Tremor | Coarse hand tremor | Hallmark of withdrawal | | Autonomic signs | Tachycardia, hypertension, diaphoresis | Hyperadrenergic state | | Mental status | Mild confusion, agitation | Risk for progression to seizures/delirium tremens | | Metabolic | Normal glucose, electrolytes | Rules out hypoglycemia, hyponatremia | ### Management Algorithm ```mermaid flowchart TD A[Alcohol withdrawal suspected]:::outcome --> B{Severity assessment}:::decision B -->|Tremor, autonomic signs, mild confusion| C[Early-intermediate withdrawal]:::outcome C --> D[Benzodiazepine: Lorazepam 2-4 mg IV/IM]:::action D --> E[Thiamine 100 mg IV/IM]:::action E --> F[Folic acid + multivitamin]:::action F --> G[Supportive care, monitoring]:::action G --> H{Seizures or hallucinations?}:::decision H -->|Yes| I[Escalate benzodiazepine dosing]:::urgent H -->|No| J[Continue protocol, reassess q4h]:::action ``` **Key Point:** Benzodiazepines are the gold standard for alcohol withdrawal. Lorazepam is preferred because it has no active metabolites and can be given IV/IM, making it suitable for acute settings and patients with liver dysfunction. **High-Yield:** The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised) is used to quantify withdrawal severity and guide benzodiazepine dosing. This patient's presentation (tremor + autonomic hyperactivity + confusion) scores in the moderate range (15–20), warranting immediate benzodiazepine therapy. **Clinical Pearl:** Always give thiamine BEFORE glucose in suspected alcohol use disorder to prevent Wernicke encephalopathy. Thiamine depletion is universal in chronic alcohol users; glucose alone can precipitate or worsen thiamine deficiency. **Warning:** Haloperidol (antipsychotic) is contraindicated as monotherapy in alcohol withdrawal because it lowers seizure threshold and does not address the underlying autonomic hyperactivity. It may be used adjunctively for hallucinations only AFTER benzodiazepine initiation. ### Why Lorazepam Over Other Benzodiazepines? - **No active metabolites** → safe in hepatic impairment (common in chronic alcohol users) - **Rapid onset** (5–10 min IV) → critical for acute agitation/seizure risk - **Flexible route** (IV, IM, PO) → adaptable to clinical scenario - Diazepam and chlordiazepoxide have long half-lives and active metabolites; less ideal in acute settings **Mnemonic:** **LORAZEPAM for ACUTE withdrawal** — **L**ong-acting benzodiazepines (diazepam) are for maintenance; **LOR**azepam is for acute crisis. [cite:Harrison 21e Ch 473]