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USMLE Step 2 CK
l Internal Medicine
Treatment. Gastric emptying should not be used because it will delay the administration
of NAC as a specific antidote. Activated charcoal is given in repeated doses. NAC is preferably given within 8 hours of the ingestion, when it is most efficacious. When >24 hours have
elapsed since ingestion, there is no specific therapy that can prevent or reverse the toxicity, but
still give NAC always. NAC and charcoal are superior to any form of gastric emptying.
ALCOHOLS (METHANOL AND ETHYLENE GLYCOL)
At the opera, you go to see the Three Tenors, who exhibit confusion, ataxia,
lethargy, drowsiness, and slurred speech; which is to say, you have really gone to
see the Three Drunken Tenors. How would you distinguish between the tenors
drunk on methanol or ethylene glycol from those drunk on simple ethanol?
Etiology. Methanol (wood alcohol) is found in paint thinner, sterno, photocopier fluid, solvents, and windshield washer solution. Ethylene glycol is most often found in automotive antifreeze. All of the alcohols are metabolized by alcohol dehydrogenase. Alcohol dehydrogenase
metabolizes methanol to formaldehyde and formic acid. Ethylene glycol is metabolized partially to oxalic acid and oxalate, which leads to kidney damage.
Note
Ingestion of methanol,
ethylene glycol, and isopropyl
alcohol will all result in an
osmolar gap.
Note
Charcoal will not inhibit the
absorption of alcohols.
Clinical Presentation. Ethanol, methanol, ethylene glycol, and isopropyl alcohol can all produce intoxication. Methanol is more characteristically associated with visual disturbances
up to and including blindness from the production of formic acid. Ethylene glycol is distinguished by the development of renal failure and oxalate crystals and stones in the urine.
Isopropyl alcohol ingestion can only be distinguished before a specific drug level is done by
the history or by the development of acidosis in the absence of an elevated anion gap.
Diagnosis. Determining specific levels of each alcohol is the most specific test. Ethylene
glycol is characterized by oxalate crystals in the urine, increasing BUN/creatinine, or by
adding fluorescein to the urine and then observing for urine fluorescence with an ultraviolet Wood’s lamp. Ingestion of methanol and ethylene glycol will be characterized by an
increased serum osmolar gap and metabolic acidosis with an elevated anion gap. Isopropyl
alcohol will produce an osmolar gap without an increased anion gap. Remember this difference when differentiating them. Ethylene glycol intoxication may also be characterized by
hypocalcemia.
Treatment. Ethylene glycol and methanol intoxication were previously treated with an ethanol infusion (to prevent the production of the toxic metabolites) followed by hemodialysis to
remove the substance from the body. Fomepizole (alcohol dehydrogenase inhibitor) is the drug
of choice. Fomepizole inhibits the production of toxic metabolites without leading to intoxication. Dialysis can be used in patients with severe anion gap metabolic acidosis or signs of endorgan damage (coma, seizures, renal failure).
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l Emergency Medicine
CARBON MONOXIDE (CO)
You are the chief resident at a great metropolitan training program at the time of
a fire at a large office building. A total of 2,500 people come to your emergency
department at the same time to be treated for smoke inhalation. Among them
is a 68-year-old man with a history of aortic stenosis who had to walk down 90
flights of stairs. What is the most important initial test for this man?
Source. Poisoning with CO occurs with exposure to various forms of burning materials, such
as gasoline, wood, and natural gas, and with entrapment in fires and smoke inhalation. Low
levels of CO poisoning are present in most tobacco smokers. CO itself is odorless and tasteless.
Metabolism. CO binds to hemoglobin 200 times more avidly than oxygen.
Carboxyhemoglobin decreases release of oxygen to tissues and inhibits mitochondria. This
results in tissue hypoxia and anaerobic metabolism similar to what would occur with anemia.
Clinical Presentation. Pulmonary symptoms include dyspnea, tachypnea, and shortness of
breath. Cardiac symptoms include chest pain, arrhythmia, and hypotension.
Early neurologic symptoms include headache (most common), nausea, blurry vision, and dizziness, while late symptoms include confusion, seizures, impaired judgment, and syncope.
Laboratory. Carboxyhemoglobin levels can give an indication of the severity of the exposure.
<10%: Levels up to 10% may occur in city dwellers who are smokers
20-30%: Mild symptoms
30-50%: Moderate to severe symptoms
>50-60%: May be fatal
Influenza is the most common misdiagnosis because most people present during wintertime.
When an entire family presents with “flu” symptoms without fever, think CO poisoning.
• Arterial blood gases or venous blood gases. Metabolic acidosis is present from the failure of carboxyhemoglobin to release oxygen to tissues. The pO2 will be normal.
• CPK may be elevated.
• Routine pulse oximetry is not helpful. Carbon monoxide pulse oximetry provides a
way to measure carboxyhemoglobin and is the initial diagnostic test for suspected CO
poisoning.
Note
In the winter of Northern
climates, space heaters
are a common cause of
carbon monoxide poisoning.
Headache is the most
common symptom. Nausea is
also very common.
Note
CO poisoning initially presents
just like hypoglycemia.
When a fingerstick glucose is
normal, this should raise your
suspicions.
Treatment
• Removal from source of exposure
• 100% oxygen administration
• Hyperbaric oxygen in severe cases
– COHb levels >25%
– Myocardial ischemia
– EKG changes
– CNS abnormalities other than headache or chest pain
– Pregnant women when carboxyhemoglobin levels >15%
In room air, carbon monoxide has a half-life of 4-6 hours, which decreases to 40-80 minutes
on 100% oxygen and to 15-30 minutes with hyperbaric oxygen.
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l Internal Medicine
CAUSTICS/CORROSIVES (ACIDS AND ALKALI)
Definition. The oral ingestion, inhalation, or cutaneous or ocular contact with a wide variety
of corrosive substances.
Etiology. The most common household acids are various toilet, drain, swimming pool, and
metal cleaners. The most common alkali ingestions or exposures are from liquid and crystalline lye, dishwasher detergents, hair relaxers, and oven cleaners. The most common serious
injury is from the oral ingestion of liquid drain cleaner.
Clinical Presentation. The most common symptoms from ingestion injury are oral pain,
drooling, odynophagia, and abdominal pain. Esophageal injury with subsequent stricture formation may occur from either acid or alkali ingestion. Gastric perforation may occur. In most
circumstances, alkali exposures are more serious than acid exposures. Alkaline substances are
more destructive to tissues.
Diagnosis. The history of exposure with subsequent characteristic injury is sufficient to
establish the diagnosis. Upper endoscopy is critical for determining the extent of the injury.
Treatment. The management of both acid and alkali caustic ingestions is essentially the same.
Immediately wash out the mouth with large volumes of cold water. Irrigate ocular exposures
with large volumes of either saline or water, followed by fluorescein staining to determine if
there is significant corneal injury. Do not induce emesis with either acids or alkaline ingestion because it can worsen the injury. Simply give water. Do not try to neutralize the acid
with a base or a base with an acid because a heat-producing reaction can occur, which would
destroy more tissue. Charcoal is not useful, nor are steroids or prophylactic antibiotics.
DRUGS OF ABUSE
Opiates
Opiate toxicity is predominantly respiratory related, via depressant effects upon the respiratory centers in the brain stem. Death can occur through acute respiratory acidosis. In addition
to their analgesic and euphoric effects, opiates also cause pupillary constriction, constipation,
bradycardia, hypothermia, and hypotension. Opiates can be rapidly reversed by naloxone.
Since opioids decrease gastric emptying by relaxation of smooth muscle, gastric lavage may be
used in cases of overdose with oral agents.
Although withdrawal of opiates is uncomfortable, it is not fatal. It is usually treated with
methadone or buprenorphine. Opiate withdrawal symptoms are the following.
• 3–4 hours: fear, anxiety, and drug craving
• 8–14 hours: insomnia, yawning, rhinorrhea, diaphoresis, mydriasis, anxiety
• 1–3 days: tremor, muscle spasms, vomiting, diarrhea, tachycardia, chills, piloerection
Cocaine
Pathophysiology. Cocaine blocks the reuptake of norepinephrine and other catecholamines
at the synapse. This leads to a wide variety of euphoric and toxic effects. Amphetamines
work in a similar way but are less likely to produce severe toxicity or death. Severe toxicity
from cocaine is far more likely with smoked (“crack”) or injected cocaine rather than snorted
(inhaled).
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Clinical Presentation. Toxic effects of cocaine are related to a very significant alpha-adrenergic stimulatory effect, resulting in very high blood pressure, hemorrhagic stroke, subarachnoid hemorrhage, myocardial infarction, arrhythmia, and seizures. These may lead to death.
Metabolic acidosis, rhabdomyolysis, and hyperthermia may also occur with cocaine toxicity.
Pulmonary edema is specific to smoked cocaine. Cocaine withdrawal results in depression from
norepinephrine depletion. There is limited physiologic withdrawal from cocaine.
Treatment. Benzodiazepines such as diazepam are used to control acute agitation. Combined
alpha/beta agents such as labetalol or alpha-blockers such as phentolamine are useful to
control hypertension. Pure beta-blockers should be avoided because they lead to unopposed
alpha stimulatory effects. There is no specific drug to reverse cocaine.
Benzodiazepines
Benzodiazepines (BZDs) produce somnolence, dysarthria, ataxia, and stupor. Very infrequently,
BZDs lead to death from respiratory depression; most deaths are associated with ethanol or
barbiturate ingestion.
Patients receiving prolonged parenteral administration of BZDs are at risk for propylene glycol poisoning (used in parenteral formulations of diazepam and lorazepam). Rarely, this may
cause hypotension, cardiac dysrhythmias, lactic acidosis, seizures, or coma.
l Emergency Medicine
Treatment. Good supportive care and monitoring are the foundation of treatment. As with
any overdose, the first step is to stabilize the patient’s airway, breathing, and circulation.
• Flumazenil is a specific antidote for BZD poisoning, although its use in acute BZD
overdose is controversial.
• In long-term BZD users, flumazenil may precipitate withdrawal and seizures.
• In BZD use for a medical condition, flumazenil may exacerbate the condition.
BZD withdrawal can be similar to the symptoms of alcohol withdrawal. Although rare, deaths
have been reported from severe withdrawal. The recommendation for treatment of severe
forms of withdrawal is the administrations of BZDs.
Barbiturates
This is a class of drugs with a large variety of long- and short-acting agents. Massive overdose
can result in death from respiratory depression or CNS depression. Barbiturates can cause hypothermia, loss of deep tendon reflexes, and loss of corneal reflexes, and could result in a coma
simulating brain death. Barbiturates may lead to absent EEG activity. Barbiturate withdrawal
may result in seizures similar to alcohol or benzodiazepine withdrawal. Although there is no
specific antidote for any of the barbiturates, you can increase the urinary excretion of phenobarbital by the use of bicarbonate. This is similar to the treatment for salicylate intoxication.
Hallucinogens
This includes a wide variety of agents such marijuana, LSD, mescaline, peyote, and psilocybin.
Although they may cause delirium and bizarre behavior, the adverse effects are often limited
to their anticholinergic effects, such as flushed skin, dry mouth, dilated pupils, and urinary
retention. The only hallucinogen associated with a potentially fatal outcome is the artificially
created, dissociative, anesthetic phencyclidine (PCP or “angel dust”), which may cause seizures.
Treatment for severe hallucinogen intoxication is with benzodiazepines.
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HEAVY METALS
Lead
Epidemiology/Source. Up to 12 million preschool children per year may be affected in the
United States. Lead is ingested from paint, soil, dust, drinking water, and in the past from
gasoline.
Metabolism. Lead can be absorbed from the GI tract, the skin, or by inhalation. GI absorption is increased by deficiencies of zinc, iron, and calcium.
Excretion is primarily through the urine (80–90%), with the remainder through the stool.
Lead poisoning is primarily a chronic condition, not acute.
Clinical Presentation
• Adults: Abdominal pain, anemia, renal disease, and neurologic manifestations, such as
headache and memory loss. Hypertension can occur as well.
• Children: Acute: abdominal pain, anemia, lethargy, seizures, and coma; chronic: irreversible neurologic damage, such as mental retardation and poor cognitive and behavioral function.
Note
Think lead in patients with
microcytic anemia and
abdominal pain.
Laboratory. Blood lead levels are the key to diagnosis and <10 µg/dL is considered acceptable.
“Lead lines” are densities seen at the metaphyseal plate of the long bones of children. They
indicate long-term exposure. Anemia and azotemia occur.
Treatment. Chelation with calcium EDTA, dimercaprol (BAL), penicillamine, or succimer
(oral therapy). In acute lead poisoning, use GI decontamination with charcoal. Urine output
should be maintained at a rate of 1–2 mL/kg/hr to aid in maximal excretion.
Management of lead toxicity/poisoning should be done according to blood lead levels:
• Mild (5−44 mcg/dL): no treatment needed; repeat level in 1 month
• Moderate (45−69 mcg/dL): 2,3 dimercaptosuccinic acid (DMSA)
• Severe (≥70 mcg/dL): DMSA + EDTA (calcium disodium edetrate)
LITHIUM
Lithium is a commonly used medication for the treatment of bipolar disorder and acute
mania. Although effective, it has a narrow therapeutic window and is associated with toxicity.
There are 2 main types:
• In acute poisoning, patients do not have a lithium burden
– Symptoms are primarily GI: nausea, vomiting, cramping, and possible diarrhea
– Progression can involve neuromuscular signs: tremulousness, dystonia, hyperre-
flexia, and ataxia
– Most common electrocardiographic finding is T-wave flattening
• In chronic poisoning, patients often have a large body burden of lithium
– Symptoms are primarily neurologic; mental status is often altered
– Progression can lead to coma and seizures if the diagnosis is unrecognized
– May be difficult to treat
– Usually precipitated by introduction of new medication which may impair renal
function or cause hypovolemic state
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Three major drug classes have been identified as potential precipitants of lithium toxicity:
• Diuretics that promote renal sodium wasting
• ACE inhibitors that reduce glomerular filtration rate (GFR) and enhance the tubular
reabsorption of lithium
• NSAIDs that reduce the GFR and interrupt renal prostaglandin synthesis
Systemic effects include renal toxicity (nephrogrenic diabetes insipidus is most severe manifestation). Lithium inhibits the action of antidiuretic hormone (ADH) on the distal renal tubule,
impairing sodium and water absorption. Other manifestations of lithium toxicity on the kidney
include renal tubular acidosis, chronic tubulointerstitial nephritis, and nephrotic syndrome.
The most common endocrine disorder secondary to chronic toxicity is hypothyroidism.
Lithium is taken up by thyroid cells and blocks thyroid hormone release from thyroglobulin,
which inhibits adenylate cyclase and prevents thyroid-stimulating hormone (TSH) from activating thyroid cells via the TSH receptor. Acute exposure to lithium can cause leukocytosis,
whereas chronic exposure can produce aplastic anemia.
Elevated lithium levels in the blood confirm toxicity, although levels may not correlate with
clinical symptoms. Serial levels may be warranted in cases of sustained-release tablets.
Treatment. Supportive therapy is the mainstay of treatment. Airway protection is crucial due
to emesis and risk of aspiration. Seizures can be controlled with BZDs, phenobarbital, or propofol. Gastric lavage may be attempted if the patients presents within 1 hour of ingestion.
l Emergency Medicine
Lithium is a monovalent cation that does not bind to charcoal; therefore, activated charcoal
has no role.
Fluid therapy is critical. The goal of saline administration is to restore GFR, normalize urine
output, and enhance lithium clearance.
Lithium is readily dialyzed because of water solubility, low volume of distribution, and lack
of protein binding. Thus, hemodialysis is indicated for patients who have renal failure (and
unable to eliminate lithium) and patients who cannot tolerate hydration (e.g., those with
CHF, liver disease, or severe toxicity meaning neurologic symptoms >4 m/Eq/L).
SALICYLATES
An elderly woman with osteoarthritis comes to the emergency department with
dyspnea, intractable nausea, vomiting, and tinnitus. She is fully alert and able to
give a good history. Her only other problem is hypertension. She is on a wide
variety of medications to reduce her pain. Her husband says she was in so much
pain lately that she took half a bottle of extra pills 30 minutes ago.
Definition. Salicylate intoxication results from the ingestion of a large amount of aspirin and
other salicylate-containing medications, resulting in a complex, systemic toxicity.
Clinical Presentation. The most common presentation is GI distress, such as nausea, vomiting, and gastritis. Salicylates are complex metabolic poisons. Tinnitus is one of the more specific complaints and is one of the best ways to identify the case, so as to answer the question:
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“Which of the following is the most likely diagnosis?” Salicylates affect respiratory function
in 2 ways: They directly stimulate the respiratory centers in the brainstem to cause a centrally
mediated hyperventilation and hyperpnea; in addition, they are directly toxic to the lungs
themselves and can cause a noncardiogenic pulmonary edema similar to ARDS. Hyperthermia
is possible. CNS toxicity such as confusion, coma, seizures, and encephalopathy can also occur.
This can cause death. Salicylates also interfere with Krebs cycle and lead to a metabolic acidosis
through the reversion to anaerobic glycolysis as a method of energy production in the body. In
other words, salicylates lead to significant lactic acid production with metabolic acidosis and an
elevated anion gap. This ultimately results in a compensatory respiratory alkalosis.
Diagnosis. The most specific test is an aspirin level. Suggestive findings are an elevated anion
gap with metabolic acidosis. However, a respiratory alkalosis may be the predominant defect,
especially early on. Hence the blood gas can show a low pH, a high pH, or a normal pH. An
elevated prothrombin time and hypoglycemia may also occur. The chest x-ray may be normal
or occasionally show pulmonary edema.
Treatment. If the patient comes within the first hour after ingestion, gastric decontamination
may be attempted. Charcoal is also useful, as it is in many types of ingestions. The mainstay
of therapy, however, is by trying to increase urinary excretion by alkalization of the urine along
with aggressive fluid resuscitation to maximize urinary output. When the urinary pH rises,
this will charge the salicylate molecule, which is a weak acid. This will block the reabsorption
of the substance at the kidney tubule. Dialysis is sometimes necessary.
Indications for dialysis:
• Renal failure
• CHF
• ARDS
• Persistent CNS symptoms (confusion/seizures)
• Hemodynamic instability
• Severe acid/base or electrolyte imbalance
• Hepatic failure with coagulopathy
• Salicylate level >100 mg/dL
DIGOXIN
Epidemiology. Toxicity occurs from a suicide attempt or accidentally during therapeutic use.
Toxicity is more common with renal failure because 60% of digoxin is normally excreted
renally, and it will accumulate. The most common precipitating cause of digitalis toxicity
is the reduction of potassium stores, which occurs often in patients with heart failure due
to diuretic therapy or secondary hyperaldosteronism. Hypokalemia predisposes to toxicity
because potassium and digoxin bind to the same site on the sodium-potassium ATPase pump,
leading to increased intracellular calcium, thus leading to increased cardiac contractility.
Drugs that have been implicated in digoxin toxicity include amiodarone, beta blockers, diltiazem, cyclosporine, macrolide antibiotics, indomethacin, spironolactone, and furosemide.
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Presentation. GI symptoms are most common: nausea, vomiting, diarrhea, and anorexia.
Neurologic and visual symptoms include blurred vision, color vision abnormality, hallucinations, and confusion. Cardiac disturbance is predominantly secondary to arrhythmia.
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Laboratory. EKG abnormalities are most common. Bradycardia, premature contractions,
ventricular tachycardia, and any other type of arrhythmias may be seen. Paroxysmal atrial
tachycardia is the most common arrhythmia. Hyperkalemia occurs acutely from inhibition of
Na+/K+ ATPase by digoxin. A serum digoxin level should be ordered in patients you suspect
of being toxic (history, etc.).
Treatment
• GI decontamination with repeated doses of charcoal is effective.
• Digoxin-specific antibodies (Digibind®) are useful for life-threatening toxicity, particularly with arrhythmias.
• Electrolyte abnormality correction: Potassium correction is most important.
• Antiarrhythmic medications, such as phenytoin and lidocaine, are used as necessary
with ventricular arrhythmias.
• Pacemaker placement may be necessary for bradycardia or third-degree AV block
refractory to atropine.
TRICYCLIC ANTIDEPRESSANTS
l Emergency Medicine
A 28-year-old man with a history of depression comes to the emergency
department one hour after a suicide attempt with his tricyclic antidepressants and
benzodiazepines. He is stuporous with a respiratory rate of 7/min. An EKG shows
a wide QRS. What would you do next?
Etiology/Pathophysiology. Tricyclic antidepressants (TCAs) are characterized by a number
of anticholinergic and sodium channel blocker side effects. This is the predominant cause of
their cardiac and CNS toxicities.
Clinical Presentation. The most common adverse effects are anticholinergic-mediated find-
ings of dry mouth, tachycardia, dilated pupils, and flushed skin. A quick onset with rapid
deterioration is common. The most serious effects are cardiac dysrhythmia with widening of
the QRS complex, resulting in ventricular tachycardia and first-degree conduction blocks. CNS
effects include altered mental status, confusion, and seizure.
Diagnosis. Serum drug levels are the most specific test, but an EKG showing abnormalities
is more important to determine who will have serious toxicity. The EKG may be normal or
show any range of ventricular or atrial arrhythmias or conduction delays.
Treatment. TCA overdose has anticholinergic side effects, which include impaired peristalsis
and delayed gastric emptying. Charcoal is the primary treatment in the acute setting. Any sign
of cardiac toxicity should lead to the immediate use of bicarbonate. Bicarbonate protects the
heart from the TCAs. Bicarbonate is not to increase urinary excretion (as opposed to the treatment of aspirin overdose). This case also shows why patients with benzodiazepine ingestions
should generally not be treated with flumazenil. Flumazenil would reverse the effects of the benzodiazepines and therefore lead to a seizure.
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ANTICHOLINERGIC POISONING
A 65-year-old man is brought to the emergency department by his wife with
lethargy and confusion. She says that he has had a cold and has taken over-thecounter cold preparations for the last few days. On examination he is confused
and does not recognize his wife. His temperature is 39.2° C (102.5° F), pulse 130/
min and blood pressure 100/60 mm Hg. The skin is flushed, dry, and warm. The
eyes are dilated.
Definition. Anticholingeric overdose may occur in any age group with high dose, but most
commonly presents in the elderly. Anticholinergic drugs competitively inhibit binding of
the neurotransmitter acetylcholine to muscarinic acetylcholine receptors, and are commonly
called “antimuscarinic agents.” Muscarinic receptors are found on peripheral postganglionic
cholinergic nerves in smooth muscle (intestinal, bronchial, and cardiac), in secretory glands
(salivary and sweat), on the ciliary body of the eye, and in the central nervous system (CNS).
Anticholinergic agents do not antagonize the effects at nicotinic acetylcholine receptors, such
as at the neuro-muscular junction.
The onset of anticholinergic toxicity varies depending on the particular toxin, but usually
occurs within 1–2 hours of oral ingestion. Some drugs may take up to 12 hours to have an
effect. Be aware with patients on psychotropic agents.
The following medications may cause anticholinergic effects:
• Diphenhydramine
• Scopolamine and hyoscyamine
• TCAs
• Cyclobenzaprine
• Benztropine
• Belladonna
Clinical Presentation. Patients will present with the following characteristics:
• “Red as a beet”: flushed, red skin due to cutaneous vasodialation
• “Dry as a bone”: dry skin (anhydrosis) due to inability to sweat
• “Hot as a hair” anhydrotic hyperthermia
• “Blind as a bat”: mydriasis
• “Mad as a hatter”: delirium, psychosis, hallucinations, and seizures
• “Full as a flask”: urinary retention and absent bowel sounds
• Tachycardia
Treatment. ABCs, supportive care, EKG monitoring. Anticholinergic poisoning may also
cause prolonged QRS and QT intervals. In that case, sodium bicarbonate can be used to stabilize the myocyte membrane and prevent ventricular tachycardia. If a patient develops seizures,
treat with benzodiazepines, NOT with phenytoin or fosphenytoin.
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ORGANOPHOSPHATES
Etiology. Inhibits cholinesterase and has muscarinic and nicotinic effects. Patients will be farmers or gardeners.
Nicotinic effects are weakness and decreased respiratory drive. Muscarinic effects are as follows, otherwise known as DUMBELSS syndrome:
• Defecation
• Urinary incontinence
• Muscle weakness, miosis
• Bradycardia/bronchospasm
• Emesis
• Lacrimation
• Salivation
• Seizure
Diagnosis. Check RBC cholinesterase levels. Do not delay treatment while waiting for results.
Treatment. First step is for physician to put on protective clothing, as organophosphates are
absorbed by the skin. Then, have patient remove clothing immediately. Start atropine immediately to treat the bradycardia. Start pralidoxime (2-PAM), which restores cholinesterase
activity and reverses both the nicotinic and muscarinic effects.
l Emergency Medicine
ALCOHOL
A 35-year-old man is brought to the emergency department by his wife after he had
a seizure. He is agitated and combative. He is yelling and trying to hit the nurses, and
tells you that he is in France. He is also yelling at his mother, who is not in the room.
His wife tells you that he drinks a liter of whiskey a day, though he has not had any
in the last few days because he didn’t have the money. His pulse is 130/min, blood
pressure 160/90 mm Hg, and respirations 24/min. He is diaphoretic and extremely
irritable. His temperature is 38° C (100.4° F). The rest of the exam is unremarkable.
Presentation. Alcoholics may present with any one of the following:
Mild withdrawal:
Symptoms are tremors, tachycardia, and anxiety. Seizures may be seen 6–12 hours after
the last drink.
Delirium tremens (DT):
• Manifests 48–72 hours after the last drink but can last up to 10 days
• Mental confusion
• Autonomic hyperactivity
• Visual hallucinations
• Severe agitation
• Diaphoresis
Note
The diagnosis of all alcohol
withdrawal–related syndromes
is made clinically, not by lab
values.
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