Thursday, August 9, 2012

Delirium Tremens

CIWA protocol


Delirium Tremens
Last night we had, as Dr. McNeely put it, "a tsunami of alcoholics". Here are some pearls on Delirium Tremens or the "Rum Fits"

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). 
4) How to Treat:
  • 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
kallen.jpg

No comments :