Monday, December 31, 2007

Happy New Year's

You pull the short straw and get stuck with the New Year's Eve shift. A van pulls up to the curb of your ER and rolls a body out onto the doorstep before driving away. The patient looks like he's in his early 20s. He stumbles around looking pretty unsteady. You can't really elicit a history from him; his speech is slurred and he seems to have some memory impairment. His eyes look like this (click on image to make it move!):

With a big sigh, you run tests and rule out head trauma, hypoxia, hypothermia, hepatic encephalopathy, and other metabolic disarrangements. There is an elevated osmolal gap.

Challenge 1: What's the diagnosis? What's seen on the image?

Two days later, a different patient is brought into your ER by the police; he was seen on the streets shouting about the ninjas attacking him and vomiting. He looks to be in his mid-30s and he is very disoriented. He can only tell you about the pink elephant in the room, and any attempt to calm him just riles him up more. On exam, you find tachycardia, tachypnea, hypertension, a low grade fever, and marked diaphoresis. One of the bystanders comments that he's "seen this man before - he's always drinking and panhandling for more booze."

Challenge 2: What's the diagnosis?

Image shown under GNU Free Documentation License.


Alex said...

nystagmus ; i don't know the diagnosis - did you get a blood alcohol level?

i think one of the cool alcohol-related syndromes is wernicke-korsakoff, is that it?

Craig said...

Happy New Year’s

The first case is a pretty straightforward case of alcohol intoxication. The eyes show nystagmus, and along with gait disturbance, lack of coordination, slurred speech, memory impairment, and elevated osmolal gap in a man in his early 20s on New Year’s Eve, suspicion for alcohol intoxication is high. It is still a diagnosis of exclusion. Dextrose should be given in hypoglycemia and thiamine in coma to prevent Wernicke’s encephalopathy.

The second case is the typical presentation of the DT’s. Delirium tremens is a serious manifestation of alcohol withdrawal, characterized by hallucinations, disorientation, tachycardia, hypertension, low grade fever, agitation, and diaphoresis. They begin 48-96 hours after the last drink, lasting 1-5 days, with a mortality of up to 5%. Risk factors include previous history, history of sustained drinking, age greater than 30, presence of concurrent illness, and greater number of days since last drink. This presentation also occurred around New Year’s, a time of many resolutions. DTs are treated with IV diazepam until patient is no longer delirious, risk of aspiration is low, and gut absorption is reliable. Refractory DTs require ICU admission, mechanical ventilation, and high dose benzodiazepines. Other alcohol withdrawal symptoms include insomnia, tremulousness, anxiety, GI upset, headache, palpitations, anorexia, and tonic-clonic seizures.

Sources: Wikipedia, UpToDate.