Delirium tremens

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  • 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 related disease processes

Altered mental status

Diffuse brain dysfunction

Primary CNS disease or trauma


General Psychiatric


  • 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


  • 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


  • ICU admit

See Also

External Links


  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.