3. Thiamine and folic acid should be administered

Benzodiazepines are preferred and are considered first-line treatment in patients with alcohol withdrawal (1). These agents reduce the symptoms of withdrawal including seizures and help to prevent symptom progression. Phenytoin is ineffective in preventing alcohol withdrawal seizures (1).

Due to the likelihood of nutritional deficiencies in patients with alcohol withdrawal, , thiamine and folic acid should be routinely administered (1). Folic acid supplementation and thiamine 100 mg daily are recommended to prevent the development of Wernicke's encephalopathy.

For aspiration pneumonitis, early prophylactic antibiotics are not recommended (2). This practice is believed to lead to the selection of more resistant organisms.

Sedation was discontinued and the patient became responsive. On the third day a spontaneous breathing trial was initiated which the patient passed. However, shortly after extubation, he required reintubation for tachypnea and hypoxemia. He was noted to have a poor cough and thick oral secretions. Despite again passing a spontaneous breathing trial, he again failed extubation on day five. A repeat chest x-ray was performed (Figure 2).

Figure 2. Repeat portable AP radiograph of the chest.

Which of the following should be performed? (Click on the correct answer to proceed to the third of six pages)

  1. Bronchoscopy
  2. Thoracentesis of the left pleural effusion
  3. Ultrasound of the left chest
  4. 1 and 3
  5. All of the above

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