- Most severe form of alcohol withdrawal
- Onset 48 to 96hrs after last drink
Diffuse brain dysfunction
Primary CNS disease or trauma
- Organic causes
- Psychiatric causes
- Generally a clinical diagnosis, however comorbidity is common so additional work-up/screening is required:
- Serum glucose
- Serum ethanol
- Metabolic panel
- Drug screen if concern for coingestion
- 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
- 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
- At risk for thiamine deficiency, but no symptoms: thiamine 100mg PO q day
- Give multivitamin PO; patient at risk for other vitamin deficiencies
The majority of chronic alcoholics do NOT require a banana bag
- 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
- Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for Delirum Tremens
- ↑ 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.
- ↑ Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
- ↑ Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.
- ↑ 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.