Best Choice of Treatment for Delirium Tremens

This topic has moved to the main topic on Delirium Tremens

Clinical Vignette: Preventing Complication in A Man with Agitation

A 30-year-old man, who is a heavy alcohol drinker, presented to the emergency department with agitation, altered sensorium, marked tremors, visual hallucinations. On assessment, he is unaware of the time, place, and person. His blood pressure and pulse were 160/11 and 115/min on arrival but fluctuated on monitoring. A GP had given him haloperidol IM and diazepam IV to control his behavioral disturbance. 

What treatment-complication could arise?

a)       Seizures
b)      Over-sedation
c)       Respiratory depression
d)      Arrhythmia
e)       Worsening agitation

Benzodiazepines for the Treatment of Catatonia
Safest Treatment Option for Delirium Tremens
WHO Alcohol Withdrawal Treatment Guidelines

Delirium Tremens

Delirium Tremens

Delirium Tremens is an emergent situation, that we may regard as the most severe form of alcohol withdrawal syndrome. In most cases, it occurs after long-term heavy use. It may also occur in patients who stop benzodiazepines. 

In most cases, it occurs after long-term heavy use of alcohol. 

Presentation

Psychological and behavioural manifestations

1. Rapidly changing picture

Clouding of Consciousness

1. Disorientation
2. Disorganised mental activity
3. Short term memory disturbance

Perceptual abnormalities

1. Hallucinations
2. Visual misinterpretations
3. Illusions
4. Cocaine bugs (formication)

Behavioural manifestations

1. Agitation
2. Shouting
3. Restlessness
4. Fear
5. Sleeplessness 

Physical Manifestations

General Physical

1. Dehydration
2. Electrolyte disturbances

Autonomic Manifestations

Autonomic manifestations of delirium tremens differentiate it from delirium (acute confusional state) that occurs because of organic causes other than substance use and alcohol withdrawal. 

1. Sweating 
2. Fever
3. tachycardia
4. Raised blood pressure 
5. Dilation of pupils

Complications

1. Over salivation
2. Aspiration pneumonia
3. Cardiac arrhythmia 

Management

Recognition

Clinicians need to increase their sensitivity to suspect and recognise delirium tremens in people at risk.

Intensive care

We manage patients diagnosed with delirium tremens in the intensive care unit; delirium is a medical emergency, and delirium tremens is the worse form of it. 

Supportive Management

1. Magnesium, dextrose, and folic acid supplements for all patients
2. Prevention of seizures.
1. Very-High-Bolus benzodiazepine therapy.
2. If the above is not effective, then use phenobarbital.
3. For patients who have fits despite the above, use anaesthesia 
3. Give thiamine to prevent Wernicke encephalopathy. 
1. We give this to all patients who are in alcohol withdrawal state or delirium tremens.
4. Ventilation for patients with respiratory arrest.

The best choice of treatment for delirium tremens

1. Benzodiazepines such as diazepam may worsen symptoms of delirium but not in alcohol withdrawal delirium, (I think) because of cross-tolerance. 
2. Haloperidol is an excellent choice for treating delirium except if the cause is a neuroleptic malignant syndrome, delirium tremens, Lewy-body dementia, or Parkinson's disease. 
3. Antipsychotics cause adverse reactions in patients with Lewy-body dementia, worsens parkinsonian symptoms, and may reduce the seizure threshold in those with delirium tremens, and may increase the risk of arrhythmias because of QTc prolongation. 
4. Haloperidol does not reduce the seizure threshold as much as other antipsychotics but is notorious for arrhythmias.