Delirium tremens
Background
- Onset after last drink - 48 to 96hrs
Clinical Features
- Delirium and global confusion
- Agitation
- Autonomic hyperactivity
- Diaphoresis, tachycardia, tachypnea, hypertension, hyperthermia
Differential Diagnosis
- Ethanol toxicity
- Alcohol use disorder
- Alcohol withdrawal
- Electrolyte/acid-base disorder
Altered mental status
Diffuse brain dysfunction
- Hypoxic encephalopathy
- Acute toxic-metabolic encephalopathy (Delirium)
- Hypoglycemia
- Hyperosmolar state (e.g., hyperglycemia)
- Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
- Organ system failure
- Hepatic Encephalopathy
- Uremia/Renal Failure
- Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
- Hypoxia
- CO2 narcosis
- Hypertensive Encephalopathy
- Toxins
- TTP / Thrombotic thrombocytopenic purpura
- Alcohol withdrawal
- Drug reactions (NMS, Serotonin Syndrome)
- Environmental causes
- Deficiency state
- Wernicke encephalopathy
- Subacute Combined Degeneration of Spinal Cord (B12 deficiency)
- Vitamin D Deficiency
- Zinc Deficiency
- Sepsis
- Osmotic demyelination syndrome (central pontine myelinolysis)
- Limbic encephalitis
Primary CNS disease or trauma
- Direct CNS trauma
- Diffuse axonal injury
- Subdural/epidural hematoma
- Vascular disease
- SAH
- Stroke
- Hemispheric, brainstem
- CNS infections
- Neoplasms
- Paraneoplastic Limbic encephalitis
- Malignant Meningitis
- Pancreatic Insulinoma
- Seizures
- Nonconvulsive status epilepticus
- Postictal state
- Dementia
Psychiatric
General Psychiatric
- Organic causes
- Psychiatric causes
Evaluation
- Generally a clinical diagnosis, however comorbidity is common so additional work-up/screening is required:
- Labs:
- Serum glucose
- Serum ethanol
- CBC
- Metabolic panel
- LFTs
- CK
- Drug screen if concern for coingestion
- Imaging:
- CXR in all patients (pneumonia is most common infection)
- Consider head CT if evidence of head trauma, focal deficits, or other concerning findings
- Consider LP if concern for meningitis
Management
- Goal = sleepy but arousable with HR <110
- Escalating doses of benzodiazepines and phenobarbital[1]
- Diazepam IV pushes q5-10 min
- 10mg x2 → 20mg x3 → 40mg x3 = 200mg total diazepam
- If still agitated/hyperdynamic after 200mg of diazepam:
- Phenobarbital IV push q5-10min, x3 escalating doses
- Phenobarbital 65mg → 130mg → 260mg IV
- If still agitated after phenobarbital → intubate and sedate with propofol and fentanyl
- Thiamine 100mg
- Magnesium, folate, dextrose-containing IVF
- Vitamin B12
Special Situations
- The propylene glycol diluent in lorazepam, phenobarbital and diazepam, may induce a hyperosmolar anion gap metabolic acidosis if given as a drip in high doses ≥ 48hrs[2]
- Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for Delirum Tremens
Disposition
- ICU admit
See Also
- Alcohol withdrawal
- Alcohol withdrawal seizures
- Altered mental status
- EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal
External Links
- MDCalc - CIWA-AR Calculator
- See crashingpatient.com DT treatment algorithm
References
- ↑ Gold JA et al. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. 2007 Mar;35(3):724-30.
- ↑ Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.