Chapter 75: Alcohol Withdrawal: Cold Turkey Can Land You in Hot Water Level I

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Describe the signs and symptoms of acute alcohol withdrawal syndrome.

• Explain the common laboratory abnormalities seen in alcohol-dependent patients.

• Develop a treatment plan for acute alcohol withdrawal and alcohol-related seizures.

• Recommend an appropriate pharmacotherapeutic regimen for electrolyte replacement in an alcohol-dependent patient.

PATIENT PRESENTATION

Chief Complaint

“My husband has been acting strange, sweating, and shaking all day. I think he had a seizure an hour ago.”

HPI

Brian Johnson is a 54-year-old man who is brought to the ED by his wife. She states that her husband has abused alcohol since she met him while in college. She states that his typical daily consumption for the past 25 years has averaged about 14–18 alcoholic beverages. She reports that he has not been able to afford to drink recently due to a recent layoff from his job. In an effort to save money, he has decided to quit drinking “cold turkey.” He has not had any alcohol to drink in the previous 48 hours.

PMH

• Alcohol abuse and dependence

• Alcohol withdrawal with seizure 4 years prior

• Hypertension × 10 years

• GERD × 4 years

SH

• The patient is an unemployed construction worker. He has not worked for the past 6 months. He has been married for 22 years. He has been a heavy drinker for past 25 years. Drinks an average of 16 drinks (usually beer- or whiskey-containing drinks) per day.

• (+) Tobacco history—quit 5 years ago.

• Denies any illicit drug use.

Meds

• Hydrochlorothiazide 25 mg PO daily

• Amlodipine 5 mg PO daily

• OTC omeprazole 20 mg PO as needed for heartburn symptoms

All

NKDA

ROS

The patient exhibits overall confusion and is not responsive to questions. Wife states his mental status was normal until this afternoon when his confusion, sweating, and shakiness started.

Physical Examination

Gen

Tall, thin, undernourished-appearing male, in mild distress who is acutely confused and tremulous

VS

BP 162/85 mm Hg, P 107 bpm, RR 20, T 38.3°C; Wt 76 kg, Ht 6′6″

Skin

Moist, diaphoretic

HEENT

Head—atraumatic, icteric sclera, PERRLA, EOMI, mild AV nicking on funduscopic exam

Neck/Lymph Nodes

Supple, no thyromegaly or lymphadenopathy