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Stem
A 48-year-old man with a 25-year history of heavy alcohol use (roughly 100 units per week) is admitted to hospital three days after his last drink following a fall at home. On examination he is disoriented, agitated and tremulous, with a temperature of 38.2 degrees C, heart rate 124 per minute, blood pressure 174/100 mmHg, and he reports seeing insects crawling on the walls. Bedside glucose is 3.1 mmol/L; sodium 134 mmol/L; CT brain is unremarkable.
Questions
a) What is the most likely diagnosis, and what clinical stage of withdrawal does this represent? (2 marks)
The diagnosis is alcohol withdrawal with delirium tremens (DTs) — the patient is in the 48 to 72 hour stage, characterised by the cardinal features of confusion, vivid visual hallucinations, severe autonomic instability (fever, tachycardia, hypertension) and agitation. Untreated mortality is 5 percent; this is a medical emergency requiring ICU-level care.
b) List the immediate management priorities in the first hour, including pharmacological agents with doses and routes. (3 marks)
- ABCDE, secure airway, IV access, continuous monitoring (HR, BP, SpO2, GCS, temperature).
- IV thiamine 300 to 500 mg BEFORE any IV glucose (this patient is hypoglycaemic and at risk of Wernicke — glucose alone precipitates/exacerbates it), then treat hypoglycaemia with IV dextrose.
- IV benzodiazepine for symptom control and seizure/DT prevention — lorazepam 2 mg IV or diazepam 10 mg IV, repeated every 5 to 15 minutes until lightly sedated; high cumulative doses may be required. Symptom-triggered dosing via CIWA-Ar thereafter.
- IV fluids, correct electrolytes (Mg, K, PO4), paracetamol for fever if required, treat any intercurrent infection.
- Investigate fever (blood cultures, CXR, urinalysis) — do not assume withdrawal is the only process.
c) Describe the CIWA-Ar scoring system and how it guides ongoing benzodiazepine therapy. (3 marks)
The CIWA-Ar (Clinical Institute Withdrawal Assessment — Alcohol, revised) is a 10-item scale (maximum score 67): nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache/fullness in head, and orientation. Interpretation: under 8 mild or no withdrawal (no pharmacological treatment, supportive care and monitor); 8 to 15 moderate (consider benzodiazepine, ward-based); over 15 severe (inpatient IV benzodiazepine, high risk of seizures and DTs). Symptom-triggered dosing — administering a benzodiazepine dose whenever the CIWA-Ar exceeds a threshold and reassessing hourly — is superior to fixed-schedule dosing because it reduces total benzodiazepine dose, treatment duration and complication rates.
d) Outline the long-term pharmacological and psychosocial management to prevent relapse after detoxification. (2 marks)
Pharmacological (first-line AUD maintenance agents): naltrexone 50 mg PO daily (mu-opioid antagonist, reduces craving and heavy drinking; baseline LFTs; avoid in opioid use), OR acamprosate 666 mg TDS (glutamate modulator, post-detox craving; renal-dose), OR disulfiram 200 mg daily (aldehyde dehydrogenase inhibitor; aversive reaction; supervised dosing). Extended-release naltrexone 380 mg IM monthly is an alternative. Psychosocial: CBT, motivational interviewing, contingency management, 12-step facilitation (AA), family therapy, residential rehabilitation as needed. Screen for and treat psychiatric comorbidity (depression, anxiety), harm reduction, and long-term follow-up as SUD is a chronic relapsing-remitting illness.