Review Question - QID 109329

Action	Numeric Key	Letter Key	Function Key
Choose 1	1
Choose 2	2
Choose 3	3
Choose 4	4
Choose 5	5
Submit Response			Enter
Previous Question			Left Arrow
Next Question		N	Right Arrow
Open/Close Bookmode		C
Open Image			Spacebar

Benzodiazepines Introduction Metabolism QID: 109329 (M1.NE.17.4799)

QID 109329 (Type "109329" in App Search)

A 61-year-old man presents to the emergency department due to severe malaise. He reports that he began developing tremors, irritability, and severe anxiety approximately 18 hours prior to presentation. He also states that he hears his recently deceased brother speaking to him. Within the past few hours he developed severe nausea and vomited twice. His past medical history is notable for multiple prior hospitalization for acute pancreatitis. He has a 35 pack-year smoking history and drinks multiple alcoholic beverages a day. However, the recent death of his brother motivated him to stop drinking. His temperature is 100.2°F (37.9°C), blood pressure is 150/90 mmHg, pulse is 130/min, and respirations are 22/min. On physical examination, he appears diaphoretic, anxious, and has scleral icterus. Clinical hand findings are shown (Figure A). In addition to fluid resuscitation and vitamin repletion, which of the following would be the best next step in management for this patient?

Type & Select Correct Answer

Type in at least one full word to see suggestions list

Chlordiazepoxide

14%

57/395

Lactulose

18%

71/395

Midazolam

12%

47/395

Rifamixin

18/395

Lorazepam

46%

181/395

Select Answer to see Preferred Response

Review TC In New Tab

The patient in this vignette presents with auditory hallucinations, malaise, and autonomic hyperactivity (e.g., tremor, tachycardia, and irritability), which suggests the diagnosis of alcohol withdrawal. In light of this patient's history of cirrhosis, the best next step in management is a benzodiazepine taper with lorazepam, which is not dependent on hepatic metabolism.

Benzodiazepines are commonly used in the treatment of moderate to severe alcohol withdrawal because benzodiazepines and alcohol allosterically modulate the same GABA-A ligand-gated channel. Diazepam and chlordiazepoxide are the benzodiazepines of choice in most cases; however, in patients with hepatic comorbidities, a benzodiazepine that is not dependent on hepatic metabolism is indicated. These included lorazepam, oxazepam, and temazepam (LOT).

Figure A shows palmar erythema, a clinical finding that can be found in cirrhosis.

Incorrect Answers:
Answer 1: Chlordiazepoxide is a long-acting benzodiazepine that is often used to treat alcohol withdrawal. However, as it is dependent on liver metabolism, it is contraindicated in patients with hepatic comorbidities.

Answer 2: Lactulose is a non-absorbable sugar that is used in hepatic encephalopathy to acidify the gut lumen, thereby decreasing ammonia reabsorption. It is not used in the setting of alcohol hallucinosis unless hepatic encephalopathy is suspected.

Answer 3: Midazolam is a short-acting benzodiazepine that is sometimes used to treat alcohol withdrawal. However, as it is dependent on liver metabolism, it is contraindicated in patients with hepatic comorbidities.

Answer 4: Rifamixin is a non-absorbable antibiotic that is used in hepatic encephalopathy to kill bacteria in the gut lumen, thereby decreasing the conversion of dietary protein to ammonia.

Bullet Summary:
Benzodiazepines that are not contraindicated in impaired liver function (e.g., lorazepam, oxazepam, and temazepam) should be used to treat moderate to severe alcohol withdrawal in patients with hepatic comorbidities.

Rating

Please Rate Question Quality

4.4

(16)