The Man Who Cannot Sleep and Cannot Sit Still
A 42-year-old man is brought to the emergency department by his brother at 22:00. For 3 days he has not slept, is 'talking non-stop', and has spent his savings on a car he cannot afford. Tonight he became agitated, paced the corridor, and said people were 'watching him through the TV'. He has a history of depression treated with sertraline 100 mg daily for 2 years; he stopped it 10 days ago because he felt 'cured'. He drinks 6–8 units of alcohol most evenings but has not drunk for 3 days. On examination: HR 118/min, BP 152/94 mmHg, temperature 37.6 °C, pupils dilated, sweaty palms, fine tremor. He is oriented but distractible, with pressured speech and flight of ideas. He denies suicidal ideation but says he 'needs to keep moving'. The psychiatric unit has no beds; the medical ward has one bed.
1. What is your differential, and how do you distinguish the leading possibilities?
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Differential: alcohol withdrawal (with or without delirium tremens), a manic episode, a substance-induced psychosis (stimulants), and an underlying delirium from a medical cause.
Features favouring alcohol withdrawal/delirium tremens:
- Last drink 3 days ago - the timeline fits withdrawal (peak 48–96 hours).
- Tachycardia, hypertension, sweating, tremor, agitation, insomnia, and perceptual disturbances. Delirium tremens carries significant mortality if untreated.
Features favouring mania:
- 3 days of no sleep, pressured speech, flight of ideas, grandiosity (spending), and paranoid ideas.
- Stopping sertraline 10 days ago could precipitate a manic switch, especially if there is a bipolar diathesis.
Features favouring stimulant intoxication:
- Dilated pupils, sweating, tachycardia, paranoia, agitation - but the 3-day course and the abstinence from alcohol fit withdrawal better.
How to distinguish:
- Collateral history from the brother about previous episodes, previous mania, and drinking pattern.
- Examination and investigations: glucose, electrolytes, magnesium, LFTs, renal function, urine toxicology, infection screen, and a careful neurological exam. Delirium tremens is a medical emergency; mania rarely causes fever and autonomic instability of this degree.
- Response to treatment: benzodiazepines will calm withdrawal; they may also sedate mania but will not treat it definitively.
The judgement point: do not label this 'psychiatry' and send him to a psychiatric ward. The autonomic signs and the timeline make a medical cause likely, and the medical bed is the safer place to start.
2. He becomes more agitated and confused, with a temperature of 38.4 °C and a heart rate of 130/min. Outline your immediate management.
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Treat as delirium tremens / severe withdrawal until proven otherwise - this is a medical emergency.
- Environment and safety: quiet, well-lit side room, one-to-one nursing, avoid restraint if possible, reorient frequently. Do not leave him alone.
- Benzodiazepines are first-line: e.g., diazepam or chlordiazepoxide, titrated to symptoms using a symptom-triggered protocol (CIWA-Ar). In severe agitation with autonomic instability, IV diazepam in small titrated doses with airway support available. Do not use antipsychotics alone - they lower the seizure threshold and impair thermoregulation, and can worsen delirium.
- Thiamine before or with glucose - give parenteral thiamine (e.g., 200–300 mg) to prevent Wernicke's encephalopathy; check and correct glucose, magnesium, potassium and phosphate.
- Fluids and monitoring: IV fluids for insensible losses, continuous cardiac monitoring, hourly observations, and a seizure precaution plan.
- Investigate for a precipitant: infection (chest, urine), pancreatitis, head injury, hepatic decompensation. A fever in delirium tremens may be withdrawal itself, but exclude infection.
- Escalate: this patient needs a high-dependency level of care. If the medical ward cannot provide one-to-one nursing, involve critical care.
Judgement: the correct sequence is benzodiazepine + thiamine + fluids + monitoring, not 'call psychiatry'. Once he is medically stable, arrange a full psychiatric assessment for possible bipolar disorder and an alcohol treatment plan.