A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
One hour after undergoing an uncomplicated laparoscopic appendectomy, a 22-year-old man develops agitation and restlessness. He also has tremors, diffuse sweating, headache, and nausea with dry heaves. One liter of lactated ringer's was administered during the surgery and he had a blood loss of approximately 100 mL. His urine output was 100 mL. His pain has been controlled with intravenous morphine. He was admitted to the hospital 3 days ago and has not eaten in 18 hours. He has no history of serious illness. He is a junior in college. His mother has Hashimoto's thyroiditis. He has experimented with intravenous illicit drugs. He drinks 3 beers and 2 glasses of whiskey daily during the week and more on the weekends with his fraternity. He appears anxious. His temperature is 37.4°C (99.3°F), pulse is 120/min, respirations are 19/min, and blood pressure is 142/90 mm Hg. He is alert and fully oriented but keeps asking if his father, who is not present, can leave the room. Mucous membranes are moist and the skin is warm. Cardiac examination shows tachycardia and regular rhythm. The lungs are clear to auscultation. His abdomen has three port sites with clean and dry bandages. His hands tremble when his arms are extended with fingers spread apart. Which of the following is the most appropriate next step in management?
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A
Administer intravenous lorazepamCorrect. IV lorazepam is first-line for alcohol withdrawal — it activates the GABA-A receptor like alcohol, preventing progression to seizures and DTs, and is hepatically safer than diazepam.
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B
Administer intravenous naloxoneIncorrect. Naloxone reverses opioid toxicity (miosis, respiratory depression), but this patient has autonomic HYPERactivity and dilated mental status, not opioid intoxication.
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C
Adminster intravenous dexamethasoneIncorrect. Dexamethasone has no role in alcohol withdrawal; it's used for cerebral edema, anti-inflammatory effects, or adrenal insufficiency — none applicable here.
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D
Administer 5% dextrose in 1/2 normal salineIncorrect. Dextrose-containing fluids are useful for hypoglycemia and as a maintenance fluid but don't treat the GABAergic/glutamatergic imbalance driving alcohol withdrawal symptoms.
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E
Administer intravenous haloperidolIncorrect. Haloperidol controls agitation in delirium but lowers the seizure threshold and is contraindicated in alcohol withdrawal; benzodiazepines are first-line because they replace alcohol's GABAergic activity.
↑ Tap an answer to reveal the reasoning
Answer: A. This patient has alcohol withdrawal, presenting at the classic ~6-24 hour mark after his last drink (he last drank before admission 3 days ago — wait, he hasn't eaten in 18 hours but the admission was 3 days ago, so withdrawal symptoms at this time are consistent with several days of abstinence in a heavy daily drinker). The hallmark findings are autonomic hyperactivity (tachycardia, hypertension, diaphoresis, tremor), anxiety, GI symptoms, and incipient hallucinations or perceptual disturbance (he is asking about his absent father — early hallucinosis or confusion).
First-line treatment for alcohol withdrawal is benzodiazepines, which substitute for alcohol at the GABA-A receptor and prevent progression to seizures and delirium tremens. IV lorazepam is preferred in inpatient settings because it has predictable kinetics and doesn't depend on hepatic oxidation (only on glucuronidation), so it's safer in patients with liver dysfunction. CIWA-protocol-guided dosing is standard.
Not recognizing alcohol withdrawal postoperatively is dangerous — untreated, it progresses to seizures (12-48 hours), hallucinosis, and DTs (48-96 hours) with mortality up to 5%. Always screen the surgical patient with a heavy drinking history.
**Why each option:**
**A.** IV lorazepam is first-line for alcohol withdrawal — it activates the GABA-A receptor like alcohol, preventing progression to seizures and DTs, and is hepatically safer than diazepam.
**B.** Naloxone reverses opioid toxicity (miosis, respiratory depression), but this patient has autonomic HYPERactivity and dilated mental status, not opioid intoxication.
**C.** Dexamethasone has no role in alcohol withdrawal; it's used for cerebral edema, anti-inflammatory effects, or adrenal insufficiency — none applicable here.
**D.** Dextrose-containing fluids are useful for hypoglycemia and as a maintenance fluid but don't treat the GABAergic/glutamatergic imbalance driving alcohol withdrawal symptoms.