Delirium tremens

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  • Onset after last drink - 48 to 96hrs

Clinical Features

  • Delirium
    • Disconnected from the environment
  • Hyperdynamic vital signs
  • Febrile

Differential Diagnosis

Altered mental status

Diffuse brain dysfunction

Primary CNS disease or trauma


General Psychiatric


  • Consider CTH
  • Consider infectious w/u, to include LP


  • Goal = sleepy, but arousable w/ 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
    • Goal with pt sleepy but arousable, with HR < 110 bpm
    • 10 mg x2, 20 mg x3, 40 mg x3 = 200 mg total
    • If still agitated/hyperdynamic after 200 mg of diazepam:
      • 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

  • 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



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.