Delirium Tremens
1)What is it: It is a state of severe psychomotor agitation and sympathetic overdrive in chronic alcoholics who have been abstinent for ~ greater than48-96hrs, but can occur up to 7-10 days since the last drink. It also happens to be the name of a brand of Belgian golden ale as seen above!
2) When to suspect it:
- Prolonged daily alcohol consumption
- Symptoms of withdrawal even while serum etOH levels are still elevated
- Prolonged period of abstinence
- Comorbidities
- Increasing age
- History of DTs
3) What to expect:
- Psychomotor agitation: anxiety, delirium, tremor, hallucinations, seizures,
- Autonomic dysfunction: hyperthermia, hypertension, tachycardia, tachypnea, diaphoresis, midriasis
- Seizures: Alcohol withdrawal seizures can occur within 12-48 hours of the last drink, and can occur without DTs. They are tonic clonic, and occur as a single seizure or a brief flurry of seizure activity. If seizures are prolonged or continue for >6 hr period other causes of seizures should be investigated (i.e. intracerebral hemorrhage).
- Benzodiazepines are the mainstay of treatment
- For patients in the acute phase of alcohol withdrawal treat with diazepam.
- Diazepam 10-20 mg PO Q1H x 3
- If unable to tolerate PO Diazepam IV 2-5mg Q5-10 min until appropriate level of sedation is achieved.
- Rather than keeping patients sedated it is better to practice symptom based treatment with the CIWA protocol
- When to start CIWA: For any patient at risk of alcohol withdrawal who has been abstinent for <12 hrs="hrs" li="li">
- When to stop CIWA: For any patient with a CIWA of less than 10 x 3 consecutive evaluations
- Hallucinations
- Can treat with Haloperidol (watch the QTc)
- Metabolic disturbance
- Treat electrolyte abnormalities, Mg, Phos, K+
- Treat malnutrition: Thiamine 100mg IV daily x 3 and folate
- IV rehydration
- Patients can have arrhythmias and should be on telemetry
- Refer to the following link regarding treatment of alcohol withdrawal: CIWA protocol
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