Delirium Tremens

[EazyE1907]

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53 year old man with history of alcohol use disorder, chronic hep c and cirrhosis. comes to the ER with a 3 day history of cough and dyspnea. chest xray is consistent with pneumonia. lab exam shows gram negative rods with large polysaccharide capsule. the patients is immediately started on antibiotics and admitted to the hospital. after 3 days in the hospital he develops tremor nausea and vomiting. he also asks to leve The hospital because "he must return to his army unit". His temperature is 38.3C, pulse is 110, respiration are 20 min and bp is 140/95. treatment with which of the following is most appropriate for the acute treatment of this patents symptoms.

diazepam
disulfiram
fomepizole
lorazepam
naltrexone
thiamine

Thoughts? will reveal my answer and thought process once i get some input. Much appreciated!

 

[notbobtrustme]

two BZDs on that list....

still would answer diazepam..

 

[EazyE1907]

two BZDs on that list....

still would answer diazepam..

Hey bob thanks for the reply man. I chose diazepam of course and i was wrong. the correct answer is Lorazepam.

according to the explanation it says that since this patient has liver disease (hep c and cirrhosis), the preferred treatment of use would be Lorazepam because it is metabolized by phase 2 conjugation which are less affected by liver disease than phase 1 process. so lorazepam and oxazepam are the preferred treatments for patients wiht liver disease.

although diazepam is used for DT, it says that it has a longer half-life than lorazepam and more active metbaolites so it would be contraindicated in this patient.

I think this question is way out of scope for what we have to know for step 1, but then again i havent taken it yet. I just thought there was something i didnt know. Now i see what people mean when they say kaplan tests alot of minutiae bs.

 

[notbobtrustme]

yea, I agree with you, that's super nitpicky. Cute factoid, but unlikely to be anywhere near as important as knowing DTs is treated with BZDs.

 

[EazyE1907]

yea, I agree with you, that's super nitpicky. Cute factoid, but unlikely to be anywhere near as important as knowing DTs is treated with BZDs.

yeah I agree. I actually just got a uworld q for the same DT concept and the answer was diazepam. Although, it did mention in the explanation briefly that shorter acting benzos were preferred in pts with liver dis. Wrote it down for schits and giggles.

 

[J ROD]

I was going to say in the hospital we usually use lorazepam and oxazepam. Valium is not preferred for the reasons mentioned above. It is very picky. But, it is a good idea to learn the differences in benzos. It will be needed more than likely in real patients.

 

[GadRads]

I'm on psych rotation now, and my psych attending pimped me on this concept after we saw a patient with liver disease who was placed on Xanax. Mnemonic for appropriate benzos in liver disease is "parking LOT" = LOT = lorazepam, oxazepam, and temazepam.

 

[GadRads]

I was going to say in the hospital we usually use lorazepam and oxazepam. Valium is not preferred for the reasons mentioned above. It is very picky. But, it is a good idea to learn the differences in benzos. It will be needed more than likely in real patients.

As stated above, I saw a patient whose management required this detail. This is why taking Step 1 after 3rd year might lead to better scores.

 

[notbobtrustme]

As stated above, I saw a patient whose management required this detail. This is why taking Step 1 after 3rd year might lead to better scores.

no question on Step 1 will ask you to differentiate between diazepam and lorezepam in a liver failure patient.

 

[GadRads]

no question on Step 1 will ask you to differentiate between diazepam and lorezepam in a liver failure patient.

It is true that this level of detail is unlikely to be on Step 1. My general point, however, was that 3rd year experience makes Step 1 easier.

 

[Instatewaiter]

no question on Step 1 will ask you to differentiate between diazepam and lorezepam in a liver failure patient.

Not true. This is a pretty common topic to know which benzos should and shouldn't be used in liver failure.
I had a very similar question on my step 1.

 

[notbobtrustme]

Not true. This is a pretty common topic to know which benzos should and shouldn't be used in liver failure.
I had a very similar question on my step 1.

I disagree, I went through all of Uworld + Rx and never saw this factoid pop up. Furthermore, it never appeared on any shelf exam nor on my Step 1.

In the grand scheme of things, knowing DT = BZD is way more high yield than memorizing which is liver metabolised.

 

[EazyE1907]

I disagree, I went through all of Uworld + Rx and never saw this factoid pop up. Furthermore, it never appeared on any shelf exam nor on my Step 1.

In the grand scheme of things, knowing DT = BZD is way more high yield than memorizing which is liver metabolised.

I agree. However this factoid IS in uworld, i came across it yesterday. Nonetheless it's good to have in the back of your mind if indeed this kind of questions pops up.

 

[J ROD]

I remember a question in UW that asked something similar too. I just went over it since I know the set at work and the drugs on it. Man, I hope I get a pharm heavy test...lol

 

[notbobtrustme]

****, i never picked up on that. Did the Uworld question have 2 BZDs? I can't recall a question like that, but it's been about 6 months since I did Uworld, so....

 

[EazyE1907]

****, i never picked up on that. Did the Uworld question have 2 BZDs? I can't recall a question like that, but it's been about 6 months since I did Uworld, so....

nah it was straight forward. Only had i bzd and that was diazepam. But it did mention in the explanation about lorazepam and liver dis briefly. It's easy to miss stuff like. The explanations are lengthy!

 

[Instatewaiter]

I disagree, I went through all of Uworld + Rx and never saw this factoid pop up. Furthermore, it never appeared on any shelf exam nor on my Step 1.

In the grand scheme of things, knowing DT = BZD is way more high yield than memorizing which is liver metabolised.

Disagree all you want but this topic will come up on Step 1 and will come back up on Step II and Step III and will be on IM, FM, surgery and any critical care boards if you opt to do those. This concept was on my step 1 exam. Learn it now.

This is a high yield clinical concept. And it is rational why it is tested whether you want to admit it or not; the people who you'll be treating for W/D or DTs are the ones who also have ETOH cirrosis and alcoholic hepatitis. If you choose the liver metabolized benzo, you'll throw them into respiratory failure after the benzos build up.

 

[EazyE1907]

Disagree all you want but this topic will come up on Step 1 and will come back up on Step II and Step III and will be on IM, FM, surgery and any critical care boards if you opt to do those. This concept was on my step 1 exam. Learn it now.

This is a high yield clinical concept. And it is rational why it is tested whether you want to admit it or not; the people who you'll be treating for W/D or DTs are the ones who also have ETOH cirrosis and alcoholic hepatitis. If you choose the liver metabolized benzo, you'll throw them into respiratory failure after the benzos build up.

that is a good point. Sooooo what else came up on your exam??? 😉

 

[guitarguy23]

Disagree all you want but this topic will come up on Step 1 and will come back up on Step II and Step III and will be on IM, FM, surgery and any critical care boards if you opt to do those. This concept was on my step 1 exam. Learn it now.

This is a high yield clinical concept. And it is rational why it is tested whether you want to admit it or not; the people who you'll be treating for W/D or DTs are the ones who also have ETOH cirrosis and alcoholic hepatitis. If you choose the liver metabolized benzo, you'll throw them into respiratory failure after the benzos build up.

Yup he right. Just to tie it to reality then to comment on the test stuff: I'm on Family now, and we have a pt. in the throws of DTs right now, and lorazepam all day is what she gets. It's kind of amazing how much you can give. Yeah and it's HY for steps and boards.