A patient with alcohol use disorder and depression presents with slurred speech and drowsiness, what is the next best step?

Next Best Step: IV Thiamine Administration

The next best step is to administer IV thiamine (Option C) before any other intervention, including glucose-containing fluids, to prevent precipitating Wernicke encephalopathy in this patient with alcohol use disorder presenting with altered mental status. 1, 2

Rationale for Immediate Thiamine Administration

• Thiamine must be given BEFORE any dextrose-containing IV fluids because glucose administration can precipitate acute thiamine deficiency and Wernicke encephalopathy in chronically malnourished alcoholic patients. 1, 2, 3

• For patients presenting with altered mental status and alcohol use disorder, parenteral thiamine (100-500 mg/day) should be administered immediately, particularly when Wernicke encephalopathy is suspected or the patient is at high risk. 1

• The clinical presentation of drowsiness and slurred speech in an alcoholic patient represents a medical emergency requiring immediate thiamine supplementation to prevent irreversible neurological damage. 1, 2

Why Other Options Are Not the Priority

• Urine drug screen (Option A) does not change immediate management and delays critical thiamine administration. While marijuana use is mentioned, this does not cause the acute presentation described and would not alter the need for thiamine. 1

• Liver function tests (Option B) are useful for long-term management but do not address the immediate life-threatening risk of Wernicke encephalopathy. These can be obtained after stabilization. 1

• Head CT (Option D) may be considered if there is concern for intracranial pathology, but thiamine administration should not be delayed while awaiting imaging. The stable vitals and clinical context suggest alcohol-related pathology rather than acute structural brain injury. 1

Subsequent Management After Thiamine

• Following thiamine administration, benzodiazepines are the gold standard treatment for alcohol withdrawal symptoms, with long-acting agents like diazepam (5-10 mg IV/IM every 6-8 hours) or chlordiazepoxide (25-100 mg orally every 4-6 hours) preferred for most patients. 1, 2, 4

• The patient's drowsiness and slurred speech may represent early alcohol withdrawal or intoxication; benzodiazepines provide seizure prophylaxis and symptom control regardless. 1, 2

• Inpatient admission is indicated given the serious presentation with altered mental status, history of alcohol use disorder, and concurrent depression (which represents a serious psychiatric comorbidity). 1

Critical Pitfall to Avoid

• Never administer IV glucose before thiamine in patients with chronic alcohol use disorder, as this is the most common preventable cause of iatrogenic Wernicke encephalopathy in emergency settings. 1, 2, 3