phuluong2k
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According to kaplan, it does not really matter whether you give dextrose or thiamine first in case of an patient who presents with altered mental status or coma
But i do some qs, they say to give thiamine first.
Which option is right ?
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| ARJ
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According to my instinct I wouldl give
Dextrose
Thiamine
Naloxone
all of them
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| an
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thiamine is better answer...administration of iv dextrose in malnourished alcoholics can exhaust whatever thiamine supplies they have and precipitate wernicke-korsakoff syndrome...after giving B1, start dextrose drip
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| frontal
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I think each case must be viewed on its own merit. If there is a high index of suspicion for Wernicke's encephalopathy (based on history- malnutrition, chronic alcoholism, malabsorption, protracted vomitting as in hyperemesis gravidarum, and on examination- apart from acute confusional state, features of brainstem dysfunction like nystagmus, extraocular ms. weakness etc), treatment with thiamine should be started. Even if the diagnosis is in doubt treatment should be given because the condition is potentially treatable. As for Dextrose, what are the indications for it? If hypoglycemia is suspected (eg. a diabetic missing a meal and the various other causes) Dextrose should be given. If dehydration is present, we can assess it clinically and preferably start an RL or a DNS drip. Apart from hypoglycemia, what are the indications for Dextrose in the patient described?
If the case is one of alcohol withdrawal (delerium tremens), I guess history will help establish the diagnosis, and in such a case, thiamine is indicated along with clomethiazole or chlordiazepoxide.
What you give first would depend on the case and on your judgement.Maybe it really doesn't matter (as Kaplan says) what is given first, as long as what should be given is given well within time, and that includes thiamine even if diagnosis is in doubt.
P.S. Please let me know the indications for Naloxone as well.
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| ARJ
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Any patient comming with altered mental status or coma-------you dont know the history, he may be unconcious or he may be in delirium. Brought to ER. Found on street.....Any circumstances without History
A patient coming to the ER should be treated for the three life threatening condition of
Hypoglycemia
Wernicke's encephalopathy
Opiod Poisoning/Toxicity -----Naloxone (narcane)
Rest all other things can wait
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| frontal
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These three drugs when no history is available (brought in unconscious, without relatives, as you've said) sounds fine.
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| phuluong2k
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Good discussion, thanks
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| an
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yes...all would be given...but the qu is which would be given first...
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| Dot
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CMDT says not to give dextrose before Thiamine(50 mg i.v initially) as it may precipitate wernick s as thiamine being Ketolase enzyme cofactor utilised comlicating the outcome.
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