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Alcohol withdrawal seizure — MRCEM SBA MCQ

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EasyMental health and behavioural emergenciesAlcohol withdrawal seizureMRCEM SBA

A 38-year-old man is brought to the emergency department after a witnessed generalised tonic–clonic seizure lasting about two minutes. He is now alert and has no focal neurological deficit or evidence of head injury. He has been drinking heavily every day for several years but stopped 24 hours ago. He is tremulous and sweating, with a pulse of 112/min. Capillary glucose is 5.8 mmol/L. He has no history of epilepsy. Which treatment and disposition plan is most appropriate?

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Correct answer: A — Offer lorazepam and admit for medically assisted alcohol withdrawal.

The seizure followed abrupt cessation of long-standing heavy alcohol use and is accompanied by tremor, sweating and tachycardia. With normal glucose, recovery to baseline and no evident injury or focal deficit, an alcohol withdrawal seizure is the leading diagnosis, while assessment for other causes must continue. NICE advises considering a quick-acting benzodiazepine such as lorazepam to reduce further withdrawal seizures, and offering hospital admission for medically assisted withdrawal when a seizure has occurred. ([nice.org.uk](https://www.nice.org.uk/guidance/CG100/chapter/recommendations)) B provides an appropriate seizure-directed medicine but misses the need for admission. C and D retain the appropriate disposition but substitute antiseizure medicines for treatment directed at alcohol withdrawal; NICE specifically advises against phenytoin for withdrawal seizures. E might suit an appropriately assessed person undergoing community withdrawal without this complication, but a seizure makes discharge for community management inappropriate. In hospital, continue clinical assessment and monitoring, manage withdrawal under a local protocol and provide thiamine as indicated. ([nice.org.uk](https://www.nice.org.uk/guidance/CG100/chapter/recommendations))

Reference: NICE CG100: Alcohol-use disorders — recommendations 1.1.1.1 and 1.1.5.1–1.1.5.3 (Last updated 12 April 2017) — https://www.nice.org.uk/guidance/CG100/chapter/recommendations