Difference between revisions of "Delirium tremens"

(Text replacement - "==Diagnosis==" to "==Evaluation==")
(Management)
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**10mg x2 --> 20mg x3 --> 40mg x3 = 200mg total diazepam
 
**10mg x2 --> 20mg x3 --> 40mg x3 = 200mg total diazepam
 
**If still agitated/hyperdynamic after 200mg of diazepam:
 
**If still agitated/hyperdynamic after 200mg of diazepam:
***Phenobarbital IV push q5-10min, x3 escalating doses
+
***[[Phenobarbital]] IV push q5-10min, x3 escalating doses
 
***Phenobarbital 65 --> 130 --> 260mg IV
 
***Phenobarbital 65 --> 130 --> 260mg IV
 
**If still agitated after phenobarb, intubation with [[propofol]] and [[fentanyl]]
 
**If still agitated after phenobarb, intubation with [[propofol]] and [[fentanyl]]
 
*[[Thiamine]] 100mg
 
*[[Thiamine]] 100mg
*Magnesium, folate, dextrose IVFs
+
*[[Magnesium]], [[folate]], [[dextrose]] IVFs
*B12
+
*[[Vitamin B12]]
  
 
===Special Situations===
 
===Special Situations===

Revision as of 22:53, 22 December 2016

Background

  • Onset after last drink - 48 to 96hrs

Clinical Features

  • Delirium
    • Disconnected from the environment
  • Hyperdynamic vital signs
  • Febrile

Differential Diagnosis

Ethanol related disease processes

Altered mental status

Diffuse brain dysfunction

Primary CNS disease or trauma

Psychiatric

General Psychiatric

Evaluation

  • Consider head CT
  • Consider infectious workup, to include LP

Management

  • Goal = sleepy, but arousable with 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
    • 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 65 --> 130 --> 260mg IV
    • If still agitated after phenobarb, intubation with propofol and fentanyl
  • Thiamine 100mg
  • Magnesium, folate, dextrose IVFs
  • 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

External Links

References

  1. 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.
  2. 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.