Difference between revisions of "Delirium tremens"

(Management)
Line 3: Line 3:
  
 
==Clinical Features==
 
==Clinical Features==
*Delirium
+
*Delirium and global confusion
**Disconnected from the environment
+
*Agitation
*Hyperdynamic vital signs
+
*Autonomic hyperactivity
*Febrile
+
**Diaphoresis, tachycardia, tachypnea, hypertension, hyperthermia
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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==Evaluation==
 
==Evaluation==
*Consider [[head CT]]
+
*Generally a clinical diagnosis, however comorbidity is common so additional work-up/screening is required:
*Consider infectious workup, to include LP
+
*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==
 
==Management==
*Goal = sleepy, but arousable with HR <110
+
*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<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>
 
*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
 
**Diazepam IV pushes q5-10 min
**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 65mg → 130mg → 260mg IV
**If still agitated after phenobarb, intubation with [[propofol]] and [[fentanyl]]
+
**If still agitated after phenobarbital → intubate and sedate with [[propofol]] and [[fentanyl]]
 
*[[Thiamine]] 100mg
 
*[[Thiamine]] 100mg
*[[Magnesium]], [[folate]], [[dextrose]] IVFs
+
*[[Magnesium]], [[folate]], [[dextrose]]-containing IVF
 
*[[Vitamin B12]]
 
*[[Vitamin B12]]
  
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<references/>
 
<references/>
  
[[Category:Psychiatry]][[Category:Toxicology]]
+
[[Category:Toxicology]]
 +
[[Category:Psychiatry]]

Revision as of 07:55, 24 December 2016

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 related disease processes

Altered mental status

Diffuse brain dysfunction

Primary CNS disease or trauma

Psychiatric

General Psychiatric

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

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.