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Thursday, 7 January 2021
Clinical Vignette: Preventing Complication in A Man with Agitation
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?
b) Over-sedation
c) Respiratory depression
d) Arrhythmia
e) Worsening agitation
Safest Treatment Option for Delirium Tremens
WHO Alcohol Withdrawal Treatment Guidelines
Tuesday, 10 January 2017
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
- Rapidly changing picture
Clouding of Consciousness
- Disorientation
- Disorganised mental activity
- Short term memory disturbance
Perceptual abnormalities
- Hallucinations
- Visual misinterpretations
- Illusions
- Cocaine bugs (formication)
Behavioural manifestations
- Agitation
- Shouting
- Restlessness
- Fear
- Sleeplessness
Physical Manifestations
General Physical
- Dehydration
- Electrolyte disturbances
Autonomic Manifestations
- Sweating
- Fever
- tachycardia
- Raised blood pressure
- Dilation of pupils
Complications
- Over salivation
- Aspiration pneumonia
- 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
- Magnesium, dextrose, and folic acid supplements for all patients
- Prevention of seizures.
- Very-High-Bolus benzodiazepine therapy.
- If the above is not effective, then use phenobarbital.
- For patients who have fits despite the above, use anaesthesia
- Give thiamine to prevent Wernicke encephalopathy.
- We give this to all patients who are in alcohol withdrawal state or delirium tremens.
- Ventilation for patients with respiratory arrest.
The best choice of treatment for delirium tremens
- Benzodiazepines such as diazepam may worsen symptoms of delirium but not in alcohol withdrawal delirium, (I think) because of cross-tolerance.
- 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.
- 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.
- Haloperidol does not reduce the seizure threshold as much as other antipsychotics but is notorious for arrhythmias.
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