Delirium Tremens

Article by Khadil Hosein, MD
Follow Up Rounds 

---

THE CASE

CC Seizure and altered mental status

Triage Vitals Temp (rectal) 101.6 °F, HR 152, BP 155/111, RR 25, SpO2 100% on RA, FS 160

HPI

• 51 y/o M for three witnessed seizures by EMS, received midazolam 10mg IM by EMS with resolution of seizure activity
• Pt mumbling and difficult to understand
• Lives with cousin who states he usually drinks 1 bottle of liquor and several beers everyday
• Last drink was one day ago.

Physical Exam

• General: Confused, agitated
• HEENT: NCAT, PEERLA, EOMI. Tongue fasciculations Non icteric. Neck supple. No nuchal rigidity.
• CV: Tachycardic, regular
• Pulm: Mildly Tachypneic with decreased basilar breath sounds. No rales or wheezes.
• Abd: Soft, NTND, normal BS.
• Musculoskeletal: No signs of trauma and Very tremulous
• Neurological: Oriented to name, GCS 11, moving all extremities
• Skin: Warm and diaphoretic
• CIWA score: >20

Studies

Chemistry

Na	128 (135 – 145) mEq/L
K	3.3 (3.5 – 5.0) mEq/L
Cl	82 (98 – 108) mEq/L
CO2	19 (24 – 30) mEq/L
BUN	5 (5 – 26) mg/dL
Creatinine	1.10 (0.1 – 1.5) mg/dL
Glucose	152 (70 – 105) mg/dL
Lactic Acid	12 mg/dL
Anion Gap	27 mEq/L

EtOH <20 mg/dL

VBG: PH 7.335 CO2: 37.5

ECG: Sinus Tachycardia

CTH: Microvascular changes, but otherwise unremarkable

Intervention

• Patient received IVF NS x 2L, Thiamine 1g IV, Folic acid 1mg, Mg 2mg IV and a total of Valium 140mg IV over 3 hours.
• Pt remained tachycardic in 120’s, hallucinating , with worsening mental status with hypoxia to 88%
• Pt was intubated for hypoxia and airway protection
• Started on a propofol drip
• Admitted to MICU for Delirium Tremens
  

  ---

Delirium Tremens

General

• Usually 48-96 hrs after last alcohol consumption
• Of those with withdrawal Seizures, 33% progress to DTs
• Mortality of 5%
• Chronic alcoholism → ↓ GABA receptors + ↑ NMDA-subtype glutamate receptors → withdrawal

Clinical Presentation of DTs

• Fluctuating disturbance of attention, awareness, orientation
• Visual Hallucinations
• Disorientation/Delirium
• Autonomic instability
  • Severe tachycardia and hypertension
  • Severe agitation and tremulousness
  • Hyperthermia (Fever, severe diaphoresis)

Management of DTs

• Thiamine + Glucose to prevent/treat Wernicke’s encephalopathy
• Check Mg
• Psychomotor agitation treatment
  • Valium
    • Preferred agent due to long duration of action 2/2 active metabolites
    • Onset of action  = 5 minutes

• In liver disease
  • Valium elimination half-life is prolonged
  • Ativan elimination half-life unchanged

• Refractory DTs
  • Benzos potentiate GABA receptors but may have insufficient agonist
  • Pts may have low endogenous levels of GABA
  • Considered if
    • >50 mg valium or >10 mg ativan is required  in 1st hour
    • Or >200 mg valium or >40 mg ativan in first 3-4 hours
  • May give phenobarb 130-260 mg IV q15-20 mins until symptom control
  • Propofol can also be used
  • Intubation often required at this point
  • Dispo: Unit

Additional Resources

• EMRAP: Alcohol Withdrawal 
• EMCrit: Delirium Tremens
• CORE EM: Phenobarbital in Alcohol Withdrawal
• CORE EM: Alcohol Withdrawal