A 34 year old man is brought to the hospital Emergency department after being found   fallen on the side of a road outside the local bar.

Which of the folowing situations is NOT a reason to intubate him?

1. He is atraumatic and is breathing at a rate of 35 breaths a minute

2. Atraumatic and breathing at a rate of 6 breaths a minute

3. He starts to have a seizure

4. He has a fever of 102.4 F

Answer is 4. All the others are reasons to intubate in any unconscious person.

In the first situation - 35 breaths/min - fatigue will set in and patient will go into respiratory failure. EXCEPTion is hyperventilation syndrome where all you need to do is give the patient a paper bag to breathe in and out of. They could also be treated with Benzodiazepines or Tricyclics.

Unconscious patients with a respiratory rate of less than 10 must be watched closely/intubated.

Unconscious patients who go into a seizure are incapable of protecting their airways. Same goes for those who are vomiting in the unconscious/drowsy state.

Fever - per-se is not an indication to intubate.

The above patient is most likely drowsy due to alcohol but immediate workup includes Blood sugar, trial of Naltrexone and assessment of intracranial pathology.

If febrile, must also check CSF and look for other causes of fever - including illicit drug usage.

Alcohol withdrawal:

The really important symptomsand signs are bolded.

Symptoms 
Anxiety or Panic Attacks 
Paresthesias, Shakes or Jitters 
Chills, Sweats, or Fevers 
Chest Pain 
Headache 
Nausea or Vomiting 
Abdominal pain 
Paranoid delusions or illusions 
Auditory and visual hallucinations 


Signs 
Blood Pressure, pulse and temperature elevated
Hyperarousal, Agitation, or Restlessness
Cutaneous Flushing or Diaphoresis
Dilated pupils 
Ataxia
Altered Level of Consciousness or Disorientation 
Delirium tremens 


Practice Guideline Committee of the American Society of Addiction Medicine

Benzodiazepines

Two ways of treating were compared:  symptom-triggered if the patient has tachycardia or agitation or fever or other signs of withdrawal.vs. scheduled therapy at regular intervals.

Symptom triggred was superior.

Median amount of chlordiazepoxide given to the symptom-triggered (PRN) group was 100mg compared to 425mg in the fixed dose group, and the median duration of treatment was only 9 hours in PRN group compared with 68 hours for fixed dose group.

Propranolol should be used as it prevents the autonomic hyperactivity classically associated with alcohol withdrawal delirium.

Clonidine

It is effective in ameliorating symptoms in patients with mild to moderate withdrawal.

Carbamazepine

Carbamazepine, in seven-day protocols for alcohol withdrawal was associated with less psychiatric distress and a faster return to work.

Carbamazepine has well-documented anticonvulsant activity and has been shown to prevent alcohol withdrawal seizures in animals studies.

Magnesium

Magnesium level is usually normal on admission, but then drops during withdrawal before spontaneously returning to normal as symptoms subside. Magnesium as a supplement to benzodiazepines showed no significant difference in severity of withdrawal symptoms.

Thiamine

Patients with alcohol dependence are frequently thiamine deficient, with a high risk for Wernicke's disease and Wernicke-Korsakoff's syndrome, both of which can be prevented by thiamine.