Severe agitation, tremors with history of alcoholism


• Pantoprazole 40 mg
• Ondansetron
• Banana bag


• Patient left ED against medical advice ~ 1 hour into ED course with IV in place


Mark Dammann, MD Oregon Health & Science University
David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center


Andy Barnett, MD Kaiser Permanente


• Anxiety
• Depression
• EtOH Abuse
• ETOH Withdrawal

Differential Diagnosis

• Anxiety
• Depression
• Suicidal ideation
• ETOH withdrawal
• Benzodiazepine withdrawal

Patient Workup

• CMP – Na 129 (low)
• EtOH- 107 (high)
• C02 – 18
• Mg – nl
• Social work consult

Key Points

• Chronic ETOH use is a risk factor for thiamine deficiency
• Thiamine and glucose indicated for prevention of Wernicke’s encephalopathy
• Delirium tremens: hallucinations, agitation, autonomic instability (tachycardia, hypertension, fever)
• DTs usually start 2-3 days after last drink, lasting up to 7 days
• 5% Mortality
• 5% of ETOH withdrawal will experience delirium tremens
• Correction of hyponatremia should not exceed 20 meq/L in 24 hours

Editor’s Notes

The patient is not in control of her thoughts or emotions. Ideally, the triage nurse would put her in a room and assist her to get completely undressed and in a gown with her belongings locked with security due to three reasons: 1. Flight risk of patient with suicidal ideation 2. To be sure patient doesn’t have a weapon of any kind, due to her current emotional state 3. That she didn’t elope with IV access for drug abuse Would consider her suicidal place a hold to prevent her eloping with suicidal ideation Once she elopes staff should call police and have them bring her back to ER to get the IV taken out and allow her to leave. Or, if suicidal, hold her. I have seen way too many OD’s that had left one ER AMA came back to us DOA from a line put in the patient in the ER–giving them access

– Michele L. Wolf, RN, MSN, ARNP-FC Interim MSN Program Director, University of Tampa , Department of Nursing

Suggested Workup

• History and physical exam
• EtOH use counseling
• Suicide risk assessment: Social work referral
• Labs: CMP, CBC, magnesium, phosphorus, urine HCG, serum ethanol, urine drug screen, UA

Suggested Treatment

• Banana bag: Thiamine, folate, and a multivitamin in isotonic saline with 5 percent dextrose
• Correct electrolyte abnormalities
• Lorazepam

Suggested References

Withdrawal Syndromes


• Gender: Female
• Age: 31 years
• Height: N/A
• Weight: N/A


• Temperature: 98 F/37.2 C
• Blood Pressure: 148/87
• Heart Rate: 98
• Respiratory Rate: 22
• Pulse Oximetry: 98%

Signs and Symptoms

Tremor; anxious feelings; sadness; hematemesis

History Medical

• Eating disorder
• Depression
• H/O suicidal ideation Social
• Consumes ETOH daily
• Denies tobacco or other drug use


• Buspirone
• Citalopram

Related videos