Delirium tremens: Difference between revisions
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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 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
- 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
- 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.
- ↑ 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.