Morning Report: Delirium Tremens

Here’s Dr. Ammon with a great Halloween edition of Morning Report!

DELIRIUM TREMENS

Most severe form of alcohol withdrawl manifested by AMS (global confusion) and sympathetic overdrive (autonomic hyperactivity).

CHRONIC ETOH -> CNS DEPESSANT -> ETOH-GABA -> inhibitory effect….

No ETOH -> OVERACTIVE CNS -> CARDIOVASCULAR COMPROMISE…

Hallucinations, disorientation, tachycardia, hypertension, fever, agitation

ED MANAGEMENT, GOAL –> target HR <120

1. ABC, IV, O2, Monitor
2. 1^ST LINE: Benzodiazepines: diazepam 5-10mg IV q5-10mins; lorazepam 2-4mg IV q15-20mins.

Refractory DT: more than 50mg diazepam or 10mg Ativan used within first hour or you reached 200mg diazepam or 40mg lorazepam.

2nd LINE: 1. phenobarbital IV repeated 15-20mins 2.Intubate, give Propofol and fentanyl

DT PROTOCOL

VALIUM IV Q5-10minutes

10 -> 10 ->20 -> 20 -> 20 -> 40 -> 40 -> 40 …… Patient still agitated?

———————————————————————————————-

1. Phenobarital IV 65 -> 130 -> 260….. OR
2. Intubate and start Propofol and Fentanyl drips

Medication Profiles:

Valium: <1min, elimination 20-50 hrs side effects: respiratory sedation, hypotension,

Ativan: onset 3-10, elimination 3-11 hrs, side effects: met acidosis (propylene glycol toxicity). Dosing 1-4mg bolus

Propofol: onset <1min, side effects: hypotension, hyperlipidemia, and propofol related infusion syndrome. Dosing: initial bolus 0.25-1.0mg/kg , infusion 5-80mcg/kg/min

Phenobarbital: onset <5mins. Elimination 53-140hrs. Side effects hypotension, sedation, hypoventilation. Dosing 100-320mg, max 600mg daily.

PEARLS:

• Be Aggressive, may require bigger dose of benzos than you’re used to, up to 200-300mg
• Target the HR in your management
• Higher mortality rates associated with electrolye and metabolic derangements

References:

1. Em Crit podcast 11, EMRAP podcast Nov 2011
2. Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med 2004; 164:1405.
3. DeBellis R, Smith BS, Choi S, Malloy M. Management of delirium tremens. J Intensive Care Med 2005; 20:164.
4. Amato L, Minozzi S, Vecchi S, Davoli M. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev 2010; :CD005063.
5. McCowan C, Marik P. Refractory delirium tremens treated with propofol: a case series. Crit Care Med 2000; 28:1781.

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Jay Khadpe MD

• Editor in Chief of "The Original Kings of County"
• Assistant Professor of Emergency Medicine
• Assistant Residency Director
• SUNY Downstate / Kings County Hospital

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