Delirium tremens: Difference between revisions

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==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
*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>
*#**[[Phenobarbital]] 65mg → 130mg → 260mg IV
**Diazepam IV pushes q5-10 min
*#If still agitated after [[phenobarbital]] → [[intubate]] and sedate with [[propofol]] and [[fentanyl]]
**10 mg x2 --> 20 mg x3 --> 40 mg x3 = 200 mg total diazepam
 
**If still agitated/hyperdynamic after 200 mg of diazepam:
{{Vitamin prophylaxis for ETOH}}
***Phenobarbital IV push q5-10min, x3 escalating doses
***Phenobarbital 65 --> 130 --> 260 mg IV
**If still agitated after phenobarb, intubation and [[propofol]]
*[[Thiamine]] 100mg
*Magnesium and dextrose IVFs


===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>
*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
*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==
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<references/>
<references/>


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

Latest revision as of 09:34, 24 October 2020

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

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.
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