Intern Report Case 3.1

Case Presentation by Dr. Jeff Cloyd

A 49-year-old woman is brought into the ED by EMS for a seizure that occurred at home.  The patient was noted to have a history of seizure disorder attributed to a closed-head injury 15 years prior. At triage, the patient began seizing and was subsequently transferred to the resuscitation room.  Her medications include phenytoin and methadone.  Her ethanol intake is approximately 1 – 2 pints of vodka daily.  She has been hospitalized for alcohol withdrawal in the past.
Physical Examination
VS: HR – 108 (triage), 142 (resus.); BP – 158/101 (triage), 204/168 (resus); RR- 28; O2 – 90% RA, 100% non-rebreather; T – 38.7 (R)
Well-developed, disheveled appearing female actively seizing.  Diaphoretic. No evidence of trauma.  Pupils equal and reactive bilaterally (5 mm to 3 mm).  Coarse gurgling breath sounds auscultated bilaterally.  Evidence of chronic IV drug abuse including skin-popping scars and pitting in the inguinal region.
Laboratory evaluation was significant for a glucose of 200, lactate of 9.1, CK 4800, negative troponin, phenytoin level 6.5.
Negative SDS.
Chest x-ray and head CT negative.
Test Your Knowledge
The most effective medications used to terminate seizures in the acute setting are benzodiazepines, and Lorazepam is a drug of choice.  Which of the following co-morbidities is most likely to affect the metabolism of Lorazepam?
A)   Chronic essential hypertension
B)   Diabetes mellitus
C)   Hepatitis C
D)   Old age
E)   Acute alcohol intoxication
While the medication of choice in the treatment of seizures of any etiology is benzodiazepines (especially alcohol related seizures), the butyrophenones (eg haldol) are particularly effective in the treatment of hallucinations associated with alcohol withdrawal. However, butyrophenones are not devoid of potential side effects including akinesia and dystonia.  Which of the following is the first line medication for treatment of these adverse effects of such a useful drug?
A) Benzatropine
B) Diphenhydramine
C) Clozapine
D) Ondansetron
E) Vitamin E
F) Lorazepam
G) Levodopa
H) Botulinum toxin
The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (2003) is a tool that was developed to be used by clinicians to score the severity of a patient’s alcohol withdrawal symptoms.  The impetus behind the production of this scale is to allow physicians to track a patient’s progress through alcohol withdrawal, as well for medical professionals to determine the need for sedative medication based on a numerical value.  Scoring components include nausea/vomiting, tremors, paroxysmal sweating, headache, anxiety, agitation, orientation, and hallucinations.  Which of the following symptom combinations indicate opioid withdrawal or a psychiatric disorder, rather than alcohol withdrawal?
A)   Diarrhea and normal orientation
B)   Fever and visual hallucinations
C)   Normal bowel activity and agitation
D)   Nausea, vomiting and headache
One standard alcoholic drink has 14 grams of EtOH – equivalent to a 12 ounce beer, 5 ounce glass of wine, 1.5 ounce shot of alcohol (whiskey, vodka).  The National Institute of Health has developed guidelines defining excessive and potentially harmful amounts of alcohol. For men under the age of 65, ____ drinks per day, or ___ drinks per week is considered potentially harmful.
A) 2, 10
B) 4, 14
C) 6, 12
D) 10, 100
Status epilepticus is a medical emergency because constant tonic-clonic seizure activity inhibits the body’s ability to oxygenate and then supply blood to the vital organs (particularly the brain). What constitutes status epilepticus?
A) Continuous, unremitting seizure lasting longer than 30 minutes.
B) Three tonic-clonic generalized seizures occurring within three minutes
C) Any seizure activity that persists where the patient does not fully recover consciousness before re-seizing
The patient was seen as a medical code called for status epilepticus, likely secondary to alcohol withdrawal.  The seizures were eventually terminated with very high doses of benzodiazepines that resulted in the need for intubation for compromise of respiratory drive and questionable obstruction.  She was admitted to the Medical ICU for continuing care of severe alcohol withdrawal.
Q1: (C)
Lorazepam is metabolized by the liver, and the half-life in patients with normal livers is 7-14 hours.  However, in patients with liver disease (like chronic hepatitis C), the metabolism of lorazepam is prolonged, resulting in the active agent remaining available in the circulation.  In the treatment of alcohol withdrawal, decreased metabolism rate is beneficial because GABA activity is extended, decreasing seizure activity longer.
Q2: (B)
Although acute dystonic and akinesthetic reactions secondary to butyrophenone administration are not common, they are very alarming to patients, staff, and family members and require prompt, appropriate treatment.  While each of these medications has been implemented in the treatment of dystonia, Diphenhydramine is the drug of choice for acute reactions and rapid treatment.  Diphenhydramine can be given IM, IV, or po, although initial treatment IM or IM is most effective for rapid resolution of symptoms.  The usual initial dose is 25 to 50 mg depending on the severity of symptoms.  Dosing can be repeated if symptoms re-appear, and patients and family members should be warned that symptoms may persist for up to one week – patients can take oral Diphenhydramine when symptoms develop and only need to seek medical care if the symptoms do not improve after administration.
Q3: (A)
Diarrhea, nausea, vomiting, and abdominal pain are common presenting symptoms in patients experiencing opioid withdrawal.  Although nausea and vomiting are also symptoms of alcohol withdrawal (and are scored on the CIWA-Ar), diarrhea and abdominal pain are not common in alcohol withdrawal, and should raise suspicion that some other process may be occurring in a patient that has abstained from alcohol for some time.  With regards to mental status, patients suffering from alcohol withdrawal often present with obvious disorientation; patients with psychiatric disorders are typically oriented to person, place, and time (although other aspects of their mental status will be incorrect).  Additionally, while both alcohol withdrawal and psychiatric disorders present with hallucinations, psychiatric hallucinations are classically auditory and alcohol hallucinations are classically visual.
Q4: (B)
According to the National Institute of Health, the number of drinks per day that exceeds a “safe” level in men under the age of 65 is 4 drinks per day / 14 drinks per week.  For women under 65, and anyone over 65, the limit is 3 drinks per day / seven drinks in one week.
Q5: (C)
Status epilepticus is defined as two or more sequential seizures without full recovery of consciousness between seizures or more than 30 minutes of continuous seizure activity.

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