View source for Delirium tremens

==Background==
*Most severe form of alcohol withdrawal
*Onset 48 to 96hrs after last drink

==Clinical Features==
*[[Delirium]] and global confusion
*[[Agitation]]
*Autonomic hyperactivity
**Diaphoresis, [[tachycardia]], [[tachypnea]], [[hypertension]], [[hyperthermia]]

==Differential Diagnosis==
{{Ethanol DDX}}
{{AMS DDX}}
{{Psych DDX}}

==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]]<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>
*#[[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]]

{{Vitamin prophylaxis for ETOH}}

===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<ref>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.</ref>
*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==
*[http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator MDCalc - CIWA-AR Calculator]
*See crashingpatient.com [http://crashingpatient.com/wp-content/pdf/DT%20protocol%205-19-09.pdf DT treatment algorithm]

==References==
<references/>

[[Category:Toxicology]]
[[Category:Psychiatry]]