Sun17October0644AM 6

A 55-year-old male previously diagnosed with alcoholic liver disease was admitted with increasing confusion. He consumed at least 40 units of alcohol weekly.

On examination he was confused with a Glasgow coma scale of 14 and had a slight flap of the outstretched hands. His temperature was 36.8°C and he had a blood pressure of 122/88 mmHg. He was noted to be jaundiced with spider naevi and palmar erythema. Abdominal examination revealed slight distension but no organomegaly.

Investigations revealed:

Serum sodium 139 mmol/L (137-144)

Serum potassium 3.6 mmol/L (3.5-4.9)

Serum urea 2.7 mmol/L (2.5-7.5)

Serum creatinine 65 µmol/L (60-110)

Serum bilirubin 65 µmol/L (1-22)

Serum aspartate aminotransferase 150 U/L (1-31)

Serum alanine aminotransferase 110 U/L (5-35)

Serum alkaline phosphatase 450 U/L (30-100)

Serum gamma glutamyl transferase 500 U/L (<50)

At that stage he was commenced on the rapid detoxification programme consisting of diazepam 20 mg at a minimum interval of two hourly (maximum dose 200 mg on 24 hours, standard regime). The following day, he was found collapsed in the bathroom on ward.

Which of the following agents is administered is most likely to lead to an improvement in his conscious level?

(Please select 1 option)

Thiamine

Naloxone

Vitamin K

Flumazenil Correct

Cefotaxime

Explanation

The dramatic decline in conscious level associated with institution of an aggressive alcohol detoxification regimen in a patient with impaired hepatic function (therefore reduced hepatic clearance) makes benzodiazepine toxicity the most likely diagnosis.

The rapid detoxification programmes now used are excellent for acute withdrawal from alcohol but should not be used in patients who are encephalopathic (as suggested by his confusion and flapping tremor).

Flumazenil reverses the effects of benzodiazepines but care must taken in its usage due to a relatively short half life when compared to benzodiazepines and the risk of provoking seizures when administered.

Causes of his encephalopathy should be sought, for example, spontaneous bacterial peritonitis, GI bleed or infection.

Answer Statistics

1

18%

2

1%

3

81%

4

1%

Times answered: 256