Difference between revisions of "Delirium tremens"

 
(23 intermediate revisions by 5 users not shown)
Line 1: Line 1:
 
==Background==
 
==Background==
*Onset after last drink - 48 to 96hrs
+
*Most severe form of alcohol withdrawal
 +
*Onset 48 to 96hrs after last drink
  
 
==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==
 +
{{Ethanol DDX}}
 
{{AMS DDX}}
 
{{AMS DDX}}
 
 
{{Psych DDX}}
 
{{Psych DDX}}
  
==Diagnosis==
+
==Evaluation==
*Consider CTH
+
*Generally a clinical diagnosis, however comorbidity is common so additional work-up/screening is required:
*Consider infectious w/u, 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 w/ HR <110
+
*Goal = sleepy but arousable with HR <110
*[[Diazepam]]
+
*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>
**Long duration of action, max effect within 5min
+
**[[Diazepam]] IV pushes q5-10 min
**Start 10mg IV
+
**10mg x2 → 20mg x3 → 40mg x3 = 200mg total diazepam
***Redose q5min after observing effect
+
**If still agitated/hyperdynamic after 200mg of diazepam:
***Can double subsequent doses until achieve goal
+
***[[Phenobarbital]] IV push q5-10min, x3 escalating doses
*[[Propofol]]
+
***Phenobarbital 65mg → 130mg → 260mg IV
**Consider intubation + propofol drip if benzo-nonresponsive
+
**If still agitated after phenobarbital → intubate and sedate with [[propofol]] and [[fentanyl]]
*[[Thiamine]] 100mg
+
 
 +
{{Vitamin prophylaxis for ETOH}}
  
 
===Special Situations===
 
===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
+
*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==
 
==Disposition==
Admit
+
*ICU admit
  
 
==See Also==
 
==See Also==
*[[Beer Potomania Syndrome]]
 
*[[Alcohol (ETOH) Intoxication]]
 
*[[Alcoholic ketoacidosis]]
 
 
*[[Alcohol withdrawal]]
 
*[[Alcohol withdrawal]]
*[[Alcohol withdrawal: Inpatient management]]
 
*[[Alcohol withdrawal: Outpatient management]]
 
 
*[[Alcohol withdrawal seizures]]
 
*[[Alcohol withdrawal seizures]]
 
*[[Altered mental status]]
 
*[[Altered mental status]]
*[[Delerium tremens]]
 
 
*[[EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal]]
 
*[[EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal]]
*[[Sedative/Hypnotic]]
 
*[[Wernicke-Korsakoff Syndrome]]
 
  
 
==External Links==
 
==External Links==
 
*[http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator MDCalc - CIWA-AR Calculator]
 
*[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==
 
<references/>
 
<references/>
  
[[Category:Psychiatry]][[Category:Toxicology]]
+
[[Category:Toxicology]]
 +
[[Category:Psychiatry]]

Latest revision as of 16:56, 10 October 2019

Background

  • Most severe form of alcohol withdrawal
  • Onset 48 to 96hrs after last drink

Clinical Features

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

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]

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

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. Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
  3. Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.
  4. 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.