Delirium tremens: Difference between revisions
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==Background== | ==Background== | ||
*Onset after last drink | *Most severe form of alcohol withdrawal | ||
*Onset 48 to 96hrs after last drink | |||
==Clinical Features== | ==Clinical Features== | ||
*Delirium | *Delirium and global confusion | ||
** | *Agitation | ||
* | *Autonomic hyperactivity | ||
* | **Diaphoresis, tachycardia, tachypnea, hypertension, hyperthermia | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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{{Psych DDX}} | {{Psych DDX}} | ||
== | ==Evaluation== | ||
*Consider [[head CT]] | *Generally a clinical diagnosis, however comorbidity is common so additional work-up/screening is required: | ||
*Consider | *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 | *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 | |||
**Diazepam IV pushes q5-10 min | |||
**10mg x2 | |||
**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 | ***Phenobarbital 65mg → 130mg → 260mg IV | ||
**If still agitated after | **If still agitated after phenobarbital → intubate and sedate with [[propofol]] and [[fentanyl]] | ||
{{Vitamin prophylaxis for ETOH}} | |||
===Special Situations=== | ===Special Situations=== | ||
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<references/> | <references/> | ||
[[Category: | [[Category:Toxicology]] | ||
[[Category:Psychiatry]] | |||
Revision as of 23:11, 7 November 2017
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 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
Vitamin Prophylaxis for Chronic alcoholics
- At risk for thiamine deficiency, but no symptoms: thiamine 100mg PO q day
- Give multivitamin PO; patient at risk for other vitamin deficiencies
Banana bag
The majority of chronic alcoholics do NOT require a banana bag[2][3]
- Thiamine 100mg IV
- Folate 1mg IV (cheaper PO)
- Multivitamin 1 tab IV (cheaper PO)
- Magnesium sulfate 2mg IV
- Normal saline as needed for hydration
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[4]
- 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.
- ↑ Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
- ↑ Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.
- ↑ 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.