In this episode of "IM Basics," host Dr. Eric Acker is joined by Dr. Michael Bass to tackle the frequently encountered topic of alcohol withdrawal. They provide a comprehensive overview, starting with the fundamental definitions and pathophysiology, moving through patient presentation, workup, and the nuances of treatment. Learn to look beyond simply ordering a protocol and gain a deeper understanding of how to manage these complex patients dynamically.

In this episode, you will learn about:

• Defining and Scoring Alcohol Withdrawal:
  • Symptoms are categorized as mild (anxiety, tremors, insomnia, palpitations) or severe (hallucinations, seizures, delirium tremens). Only about 20% of patients develop severe symptoms.
  • The DSM-5 criteria for diagnosis require two or more specific symptoms following the cessation or reduction of alcohol use.
  • The CIWA is a common scoring system used by nursing staff to guide treatment based on symptom severity.
• The Pathophysiology of Withdrawal:
  • Chronic alcohol use enhances the effect of the inhibitory GABA receptors and inhibits the excitatory NMDA receptors.
  • The body adapts by decreasing the sensitivity of GABA receptors and increasing the sensitivity of NMDA receptors.
  • When alcohol is stopped, the brain is left in a state of uninhibited excitatory stimulation.
• Timeline of Symptoms:
  • 6-36 hours after last drink: Mild symptoms like tremors, sweats, and agitation may appear.
  • 6-48 hours: Seizures can occur.
  • 12-48 hours: Hallucinations (visual, auditory, or tactile) may develop.
  • 48-96 hours: The most severe manifestation, delirium tremens (DTs), can set in.
• Patient Workup:
  • A thorough history is the most critical part of the workup, especially the timing of the last drink and the quantity consumed.
  • Labs are essential to rule out other conditions and should include a blood glucose, CBC, electrolytes, and blood cultures.
  • An ethanol level can be checked, but a patient can be in withdrawal even with a detectable alcohol level.
• Treatment Strategies:
  • Symptom-Triggered Therapy: This is the most recommended approach, where benzodiazepines are given based on a CIWA score threshold (e.g., a score greater than 8 or 10).
  • Benzodiazepines: These are the mainstay of treatment and work by stimulating the GABA receptor.
    • Lorazepam (Ativan): Slower onset (15-30 mins) but shorter duration.
    • Diazepam (Valium): Faster onset (2-3 mins) but longer half-life, which can lead to accumulation.
  • Refractory Withdrawal: For patients who don't respond to high doses of benzodiazepines, phenobarbital is an option. It can be used as a dual therapy with benzos or as a monotherapy.
  • Front-Loading: For patients at high risk of severe withdrawal (e.g., history of DTs), proactively administering high doses of benzodiazepines can be considered.
• Pearls and Pitfalls:
  • Be aware that benzodiazepines can cause paradoxical agitation in elderly patients,
  • Don't get anchored on alcohol withdrawal, especially considering hepatic encephalopathy in patients with cirrhosis.
  • Remember supportive care: thiamine, along with a multivitamin and electrolyte repletion
  • Always reassess your patient if the treatment isn't working.

In this episode of "IM Basics," host Dr. Acker is joined by Dr. Harmandip Parmar, an intern with an interest in cardiology, to break down the essentials of heart block. They cover the full spectrum of atrioventricular (AV) blocks, from incidental findings on an ECG to symptomatic emergencies. Tune in to learn how to identify, investigate, and manage these crucial cardiac conditions.

What You'll Learn in This Episode:

• Patient Presentation:
  • While many patients with heart block are asymptomatic, some may present with symptoms like fainting (syncope), lightheadedness, or chest pain.
  • Myocardial infarction (MI) can be an underlying cause of these symptoms and the heart block itself.
• ECG Findings for Different Heart Blocks:
  • First-Degree AV Block: Identified by a prolonged PR interval of more than 0.20 seconds.
  • Second-Degree AV Block, Mobitz Type I (Wenckebach): Characterized by a PR interval that gets progressively longer until a QRS complex is "dropped".
  • Second-Degree AV Block, Mobitz Type II: Features a constant PR interval length with intermittently dropped beats. These patients are often more symptomatic.
  • Third-Degree (Complete) AV Block: Shows a complete dissociation between P waves and QRS complexes, with each marching out at its own regular rate.
• Investigating the Causes:
  • A thorough workup is essential to find the underlying cause.
  • Potential causes include MI, electrolyte imbalances (like hyperkalemia), and thyroid issues.
  • A patient's medication list should be reviewed for drugs like beta-blockers, digoxin, amiodarone, and certain calcium channel blockers.
  • Other causes can include Lyme disease, inherited conditions like sarcoidosis, or recent cardiac procedures.
• Treatment and Management:
  • First-Degree and Mobitz I: Often asymptomatic and may not require urgent intervention, aside from investigating the cause.
  • Mobitz Type II: These patients are at high risk of progressing to a third-degree block and require admission. Atropine should be avoided. Definitive treatment is often a permanent pacemaker.
  • Third-Degree Block: This is an urgent condition. Management includes:
    • Giving atropine.
    • Using beta-adrenergic agonists like dopamine or epinephrine.
    • Initiating temporary cardiac pacing, followed by evaluation for a permanent pacemaker.

    Special Cases: In patients with Lyme carditis, a permanent pacemaker is often avoided as the condition typically improves within weeks.

• Additional Insights:
  • The discussion touches on "Stokes-Adams attacks," which are episodes of fainting linked to heart block.
  • The hosts explore the theory that rate control in atrial fibrillation might bombard the AV node, potentially leading to third-degree heart block over time

This episode of "IM Basics" provides a concise yet comprehensive overview of Multiple Myeloma. Dr. Eric Acker and Dr. Vinh Dao discuss the disease's non-specific presentation, diagnostic criteria (CRAB and SLIM), and essential workup procedures, including laboratory tests and imaging. The podcast also differentiates between MGUS, smoldering myeloma, and full-blown Multiple Myeloma, outlining when treatment is initiated for each. Key aspects of managing Multiple Myeloma, such as treatment modalities, handling complications like hypercalcemia and lytic lesions, and addressing immunocompromise, are covered in detail. The episode concludes with practical "pearls and pitfalls," emphasizing the importance of recognizing the disease despite its subtle presentation in an older demographic.

Don't forget to check out Dr. Dao's podcast, "Bloom Pod," which focuses on oncology and its links to other medical fields!