Alcohol withdrawal syndrome

Alcohol use disorder is a chronic pattern of drinking meeting 2 or more of 11 DSM-5 criteria within a 1-year period, screened with the CAGE or AUDIT-C and confirmed by history. First-line management combines a brief behavioral intervention and cognitive behavioral therapy with naltrexone or acamprosate, reserving disulfiram for highly motivated patients who can maintain abstinence.

Alcohol-associated hepatitis is an acute steatohepatitic syndrome, fever, tender hepatomegaly, jaundice, and leukocytosis, arising on a background of heavy chronic alcohol use. Severity is graded by the Maddrey discriminant function and the Model for End-Stage Liver Disease score, and severe disease is treated with prednisolone after infection and bleeding are excluded, guided by the day-7 Lille score.

Hepatic encephalopathy is a reversible spectrum of brain dysfunction from insufficient hepatic clearance and portosystemic shunting of gut-derived toxins, graded by the West Haven criteria and almost always triggered by an identifiable precipitant such as infection, gastrointestinal bleeding, constipation, or an electrolyte disturbance. Diagnosis is clinical, and management proceeds by treating the precipitant first, then titrating lactulose and adding rifaximin for recurrence prevention.

Benzodiazepine withdrawal is the abstinence syndrome that follows abrupt discontinuation or rapid dose reduction after regular use, and like alcohol withdrawal it can be fatal through seizures and delirium, unlike opioid withdrawal. Management reinstates the drug, converts to a long-acting agent such as diazepam, and tapers the total daily dose by 10 to 25% every 1 to 2 weeks, reserving phenobarbital for refractory or severe cases.

Neuroleptic malignant syndrome is a rare, life-threatening idiosyncratic reaction to dopamine-blocking agents, presenting days to weeks after starting or raising the dose, with fever, lead-pipe rigidity, autonomic instability, altered mental status, and a markedly elevated creatine kinase. Diagnosis is clinical. First-line management is stopping the offending drug, aggressive cooling, and IV fluid resuscitation, escalating to lorazepam, dantrolene, and bromocriptine.

Thyroid storm is a rare, life-threatening exaggeration of thyrotoxicosis with multiorgan dysfunction and mortality up to 30%, most often precipitated by discontinuation of antithyroid drugs, infection, surgery, or trauma in a patient with underlying hyperthyroidism. It is a clinical diagnosis treated emergently in the ICU with intravenous beta-blockade, a thionamide (propylthiouracil transitioning to methimazole), potassium iodide given only after the thionamide, and high-dose glucocorticoids.

Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection, identified by an acute rise in SOFA score of 2 points or more in a patient with known or suspected infection. Survival depends on recognizing the pattern early and completing the hour-1 bundle: lactate, blood cultures before antibiotics, broad-spectrum antibiotics such as cefepime 2 g IV every 8 hours, and 30 mL/kg crystalloid for hypotension or a lactate of 4 mmol/L or higher.

Status epilepticus is a generalized tonic-clonic seizure lasting more than 5 minutes, or repeated seizures without return to baseline, and is a neurologic emergency. Treatment is a timed escalation: IV benzodiazepine first, then an IV antiepileptic drug, then anesthetic coma with continuous EEG if convulsions persist.