Delirium tremens: Difference between revisions

Revision as of 23:57, 2 May 2016

Goal = sleepy, but arousable w/ HR <110
Diazepam
- Long duration of action, max effect within 5min
- Start 10mg IV
  - Redose q5min after observing effect
  - Can double subsequent doses until achieve goal
Escalating doses of benzodiazepines and phenobarbital^[1]
- Diazepam IV pushes q5-10 min
- Goal with pt sleepy but arousable, with HR < 110 bpm
- 10 mg x2, 20 mg x3, 40 mg x3 = 200 mg total
- If still agitated/hyperdynamic after 200 mg of diazepam:
  - Phenobarbital IV push q5-10min, x3 escalating doses
    - 65 --> 130 --> 260 mg
    - If still agitated, intubation and propofol
- See DT treatment algorithm
Thiamine 100mg
Magnesium and dextrose IVFs

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

Admit

↑ 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.

Authors:

@@ Line 24: / Line 24: @@
 ***Redose q5min after observing effect
 ***Can double subsequent doses until achieve goal
-*[[Propofol]]
+*Escalating doses of benzodiazepines and phenobarbital<ref>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.</ref>
-**Consider intubation + propofol drip if benzo-nonresponsive
+**Diazepam IV pushes q5-10 min
+**Goal with pt sleepy but arousable, with HR < 110 bpm
+**10 mg x2, 20 mg x3, 40 mg x3 = 200 mg total
+**If still agitated/hyperdynamic after 200 mg of diazepam:
+***Phenobarbital IV push q5-10min, x3 escalating doses
+****65 --> 130 --> 260 mg
+****If still agitated, intubation and [[propofol]]
+**See [http://crashingpatient.com/wp-content/pdf/DT%20protocol%205-19-09.pdf DT treatment algorithm]
 *[[Thiamine]] 100mg
+*Magnesium and dextrose IVFs
 ===Special Situations===