In a middle‑aged adult who suffered a motor‑vehicle accident six weeks ago and now has persistent anxiety and vertigo, who discontinued lorazepam (diazepam) four weeks ago, continues to consume alcohol, and had emergency‑department labs showing hyponatremia, mild transaminitis, mild hypocalcemia and mild hypochloremia with negative head, facial, cervical‑spine and pelvic CT scans, what are the most likely contributors to her symptoms and what is the appropriate immediate management?

Post-MVA Anxiety and Vertigo: Immediate Management Priorities

This patient's persistent anxiety and vertigo six weeks post-MVA are most likely multifactorial—stemming from post-concussive syndrome, benzodiazepine withdrawal, alcohol use disorder with metabolic derangements, and possible post-traumatic BPPV—and requires immediate cessation of alcohol, gradual benzodiazepine reinstitution followed by slow taper, correction of electrolyte abnormalities, and vestibular rehabilitation.

Primary Contributors to Current Symptoms

Post-Concussive Syndrome

• Vertigo and anxiety are classic postconcussive symptoms that can persist for 3-12 months following mild traumatic brain injury (mTBI). 1
• Approximately 58% of mTBI patients have persistent symptoms at 1 month post-injury, with dizziness being nearly universally present in all mTBI patients. 1, 2
• Patients presenting with headache, nausea, and dizziness in the ED have a 50% chance of developing postconcussive syndrome at 6 months. 1
• Post-traumatic BPPV occurs in 8.5% of head trauma cases and is more difficult to treat than idiopathic BPPV, requiring repeated physical treatments in 67% of cases versus 14% for idiopathic forms. 3

Benzodiazepine Withdrawal

• Abrupt discontinuation of benzodiazepines causes serious and life-threatening withdrawal symptoms including anxiety, unusual movements, seizures, severe mental changes, depression, hallucinations, and suicidal thoughts. 4
• Withdrawal symptoms can last for several weeks to more than 12 months, including anxiety, depression, problems sleeping, weakness, shaking, muscle twitching, and burning sensations. 4
• Benzodiazepines themselves are deliriogenic and associated with cognitive impairment, reduced mobility, falls, and addiction, but withdrawal must be gradual over many weeks to months. 1

Alcohol Use Disorder with Metabolic Complications

• The combination of hyponatremia (128 mEq/L), elevated transaminases (AST 70, ALT 46), hypocalcemia (8.4 mg/dL), and hypochloremia (94 mEq/L) indicates chronic alcohol use with hepatic dysfunction and malnutrition. 5
• Alcohol itself is a vestibular suppressant that can worsen vertigo during use and withdrawal, and chronic use impairs vestibular compensation. 6
• Hyponatremia below 130 mEq/L can cause neurological symptoms including confusion, seizures, and altered mental status. 5

Immediate Management Algorithm

Step 1: Address Benzodiazepine Withdrawal (Highest Priority)

• Reinstitute a low-dose benzodiazepine immediately to prevent life-threatening withdrawal complications including seizures. 4
• Use lorazepam 0.5-1 mg three times daily or equivalent diazepam dosing as a starting point. 1, 4
• Plan for gradual taper reducing 25% of the daily dose every 1-2 weeks, though many patients require slower tapers extending over several months. 1
• Provide written education about benzodiazepine risks and benefits of tapering, as this approach achieved 27% cessation rates versus 5% in controls. 1

Step 2: Alcohol Cessation and Metabolic Correction

• Initiate alcohol cessation with benzodiazepine coverage for withdrawal prophylaxis (dual benefit for both withdrawals). 1, 4
• Correct hyponatremia cautiously—aim for increase of no more than 8-10 mEq/L in 24 hours to avoid osmotic demyelination syndrome.
• Supplement calcium and consider magnesium, thiamine, and folate replacement given evidence of malnutrition and hepatic dysfunction.
• Monitor liver function and consider hepatology referral if transaminases worsen or synthetic function declines.

Step 3: Vestibular Assessment and Treatment

• Perform Dix-Hallpike testing to diagnose post-traumatic BPPV, which requires particle repositioning maneuvers as first-line treatment. 1, 3
• If Dix-Hallpike is positive, initiate Epley or Semont maneuvers; expect to require repeated treatments given the 67% rate of treatment resistance in post-traumatic BPPV. 3
• Avoid vestibular suppressants (antihistamines, anticholinergics) beyond acute symptom control, as they impair vestibular compensation. 6
• Refer for vestibular rehabilitation therapy, which improves cognitive function, activities of daily living, and return to work in mTBI patients. 2

Step 4: Anxiety Management

• Avoid escalating benzodiazepines for anxiety; instead, consider SSRI/SNRI antidepressants as first-line agents once withdrawal is stabilized. 1, 6
• Implement cognitive-behavioral therapy, problem-solving therapy, or supportive psychotherapy as non-pharmacological interventions. 1
• Consider integrative strategies including relaxation training, biofeedback, and desensitization exercises, which achieved 90% reduction in dizzy spells in post-MVA BPPV patients. 7

Critical Pitfalls to Avoid

Do Not Abruptly Stop Benzodiazepines

• Sudden cessation risks seizures, delirium, and death—this patient's anxiety may actually represent withdrawal rather than primary anxiety disorder. 4
• Physical dependence requires medical management with gradual taper, not abrupt discontinuation. 1, 4

Do Not Prescribe Long-Term Vestibular Suppressants

• Medications like meclizine, dimenhydrinate, or promethazine delay vestibular compensation and prolong recovery. 6
• Use only for severe acute symptoms, limiting to 3-5 days maximum. 6

Do Not Overlook Alcohol as a Confounding Factor

• Continued alcohol use will prevent vestibular compensation, worsen anxiety, perpetuate metabolic abnormalities, and increase fall risk. 6
• Alcohol cessation is non-negotiable for symptom resolution. 6

Do Not Assume Negative CT Excludes mTBI

• CT has only 20-40% sensitivity for detecting causative pathology in mTBI, and postconcussive symptoms occur despite normal imaging. 1
• Diagnosis is clinical, based on mechanism, symptoms, and temporal relationship to trauma. 1, 2

Expected Timeline and Monitoring

Short-term (1-2 weeks)

• Stabilize benzodiazepine dosing to eliminate withdrawal symptoms. 1, 4
• Initiate alcohol cessation with close monitoring for withdrawal. 1
• Correct electrolyte abnormalities and begin nutritional supplementation.
• Perform Dix-Hallpike testing and initiate repositioning maneuvers if positive. 1, 3

Medium-term (4-12 weeks)

• Begin gradual benzodiazepine taper once patient is stable. 1
• Continue vestibular rehabilitation with expectation of requiring multiple treatment sessions. 3
• Monitor for recurrence of BPPV, which occurs in 57% of post-traumatic cases versus 19% of idiopathic cases. 3
• Assess response to anxiety treatment and adjust pharmacotherapy as needed. 1

Long-term (3-12 months)

• Most adults with postconcussive symptoms recover within 3-12 months, though some have persistent symptoms. 1
• Continue vestibular rehabilitation as needed for persistent dizziness. 2
• Maintain alcohol abstinence and monitor for relapse. 6
• Complete benzodiazepine taper if possible, or maintain on lowest effective dose. 1