A 42-year-old male 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: BP 148/92 mmHg, HR 110 bpm, RR 22/min, Temperature 37.8°C. Serum sodium 128 mEq/L, serum glucose 85 mg/dL, serum magnesium 1.4 mg/dL. What is the most appropriate immediate pharmacological intervention?

Explanation

## Alcohol Withdrawal Syndrome: Acute Management ### Clinical Context This patient presents with **early-to-intermediate alcohol withdrawal** (tremor, diaphoresis, autonomic hyperactivity 18 hours post-cessation). The hypomagnesemia (1.4 mg/dL; normal 1.7–2.2) and hyponatremia (128 mEq/L) are common complications that lower seizure threshold. ### Why Lorazepam Is Correct **Key Point:** Benzodiazepines are the gold standard for alcohol withdrawal. Lorazepam is preferred over diazepam in acute settings because of: - Rapid onset (IV administration) - Shorter half-life (12–18 hours) → less accumulation in elderly or hepatically impaired patients - Can be titrated to effect ("symptom-triggered" dosing) - Effective for both seizure prophylaxis and autonomic stabilization **High-Yield:** The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol scale) score guides benzodiazepine dosing. Scores ≥8 warrant pharmacotherapy; scores ≥15 indicate severe withdrawal requiring ICU monitoring. ### Electrolyte Correction **Clinical Pearl:** Hypomagnesemia must be corrected concurrently (IV magnesium sulfate 1–2 g over 15 min, then infusion) because magnesium deficiency: - Increases seizure risk independent of alcohol withdrawal - Impairs cardiac repolarization (risk of arrhythmia) - Reduces benzodiazepine efficacy Hyponatremia should be corrected cautiously (0.5–1 mEq/L/hour) to avoid osmotic demyelination. ### Supportive Measures - **Thiamine 100 mg IV/IM daily** (prevent Wernicke encephalopathy) - **Folic acid 1 mg daily** (nutritional repletion) - **Glucose monitoring** (risk of hypoglycemia post-withdrawal) [cite:Harrison 21e Ch 474]