Metabolic, Toxic, and Deficiency Disorders
A. Metabolic disorders
B. Drugs
1. Alcohol:
a. Dependence: Consider it especially in pts with depression, unexplained neuropathy, frequent falls, liver abnormalities. Talk to pt and family members separately; assess impact on job, etc.
b. Withdrawal:
Table 14. The CAGE screening questions for alcoholism.
Do you ever think about Cutting down on your drinking?
Do you ever feel Angry when people ask about it?
Does it make you feel Guilty?
Do you ever have an Eye-opener?
1) Hx: Ask time of last drink, h/o withdrawal and nonwithdrawal seizures, detox programs. Focal seizures are rarely alcoholic; does pt have a h/o head injuries?
2) PE: Stage withdrawal severity by tremor, anxiety, level of confusion, pulse, N/V, sweatiness.
3) Tests: Chem 20, CBC, PT, PTT, ammonia, B12.
4) All potentially withdrawing pts should get:
a) Vitamins: Thiamine 100 mg IM/IV qd, folate, MVI.
b) IV fluids: No glucose until thiamine given. D5 1/2 NS + KCl at 150 cc/h.
c) Replete electrolytes: KCl, Ca/Mg/Phos.
d) GI prophylaxis: Ranitidine or sucralfate. Guaiac stools.
5) Rx of withdrawal seizures:
a) Acute: Diazepam 5-10 mg IV, or lorazepam 1-2 mg if pt. has liver dz or if drug must be given IM.
b) Chronic: ACD prophylaxis does not help unless pt also has seizures from TBI, etc.
6) Rx of acute withdrawal: Sx include ANS instability. Doses based on VS, agitation, sweating, tremor, seizures.
a) Benzo: Diazepam 15 mg q4h–20 mg q15min, OR lorazepam 3 mg q4h–4 mg q15min. Hold for somnolence, RR <12, SBP <100.
b) β-blocker or clonidine for altered VS.
c) Consider haloperidol IV/PO: Check EKG for QTc.
d) Taper: When VS and sx are stable for 24 h, then taper over 4-7 d.
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