Delirium tremens - Revision history

Danbot: Add MedicationDose entries (diazepam, phenobarbital) with SMW annotations

2026-03-20T18:40:31Z

Add MedicationDose entries (diazepam, phenobarbital) with SMW annotations

@@ Line 44: / Line 44: @@
 *The propylene glycol diluent in [[lorazepam]], [[phenobarbital]], and [[diazepam]], may induce a hyperosmolar anion gap [[metabolic acidosis]] if given as a drip in high doses ≥ 48hrs<ref>Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.</ref>
 *Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for Delirum Tremens
 ==Disposition==

Rossdonaldson1: /* Management */

2020-10-24T09:34:58Z

Management

← Older revision		Revision as of 09:34, 24 October 2020
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	*Goal = sleepy but arousable with HR <110		*Goal = sleepy but arousable with HR <110
	*Escalating doses of [[benzodiazepines]] and [[phenobarbital]]<ref>Gold JA et al. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. 2007 Mar;35(3):724-30.</ref>		*Escalating doses of [[benzodiazepines]] and [[phenobarbital]]<ref>Gold JA et al. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. 2007 Mar;35(3):724-30.</ref>
	**[[Diazepam]] IV pushes q5-10 min		*#[[Diazepam]] IV pushes q5-10 min
	***10mg x2 → 20mg x3 → 40mg x3 = 200mg total diazepam		#10mg x2 → 20mg x3 → 40mg x3 = 200mg total [[diazepam]]
	**If still agitated/hyperdynamic after 200mg of diazepam:		*#If still agitated/hyperdynamic after 200mg of [[diazepam]]:
	***[[Phenobarbital]] IV push q5-10min, x3 escalating doses		#[[Phenobarbital]] IV push q5-10min, x3 escalating doses
	****Phenobarbital 65mg → 130mg → 260mg IV		#*[[Phenobarbital]] 65mg → 130mg → 260mg IV
	**If still agitated after phenobarbital → intubate and sedate with [[propofol]] and [[fentanyl]]		*#If still agitated after [[phenobarbital]] → [[intubate]] and sedate with [[propofol]] and [[fentanyl]]

	{{Vitamin prophylaxis for ETOH}}		{{Vitamin prophylaxis for ETOH}}

	===Special Situations===		===Special Situations===
	*The propylene glycol diluent in lorazepam, phenobarbital and diazepam, may induce a hyperosmolar anion gap metabolic acidosis if given as a drip in high doses ≥ 48hrs<ref>Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.</ref>		*The propylene glycol diluent in [[lorazepam]], [[phenobarbital]], and [[diazepam]], may induce a hyperosmolar anion gap [[metabolic acidosis]] if given as a drip in high doses ≥ 48hrs<ref>Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.</ref>
	*Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for Delirum Tremens		*Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for Delirum Tremens

Rossdonaldson1: /* Management */

2020-10-24T09:33:23Z

Management

← Older revision		Revision as of 09:33, 24 October 2020
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	*Escalating doses of [[benzodiazepines]] and [[phenobarbital]]<ref>Gold JA et al. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. 2007 Mar;35(3):724-30.</ref>		*Escalating doses of [[benzodiazepines]] and [[phenobarbital]]<ref>Gold JA et al. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. 2007 Mar;35(3):724-30.</ref>
	**[[Diazepam]] IV pushes q5-10 min		**[[Diazepam]] IV pushes q5-10 min
	**10mg x2 → 20mg x3 → 40mg x3 = 200mg total diazepam		***10mg x2 → 20mg x3 → 40mg x3 = 200mg total diazepam
	**If still agitated/hyperdynamic after 200mg of diazepam:		**If still agitated/hyperdynamic after 200mg of diazepam:
	***[[Phenobarbital]] IV push q5-10min, x3 escalating doses		***[[Phenobarbital]] IV push q5-10min, x3 escalating doses
	***Phenobarbital 65mg → 130mg → 260mg IV		****Phenobarbital 65mg → 130mg → 260mg IV
	**If still agitated after phenobarbital → intubate and sedate with [[propofol]] and [[fentanyl]]		**If still agitated after phenobarbital → intubate and sedate with [[propofol]] and [[fentanyl]]

ClaireLewis at 16:56, 10 October 2019

2019-10-10T16:56:27Z

← Older revision		Revision as of 16:56, 10 October 2019
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	==Clinical Features==		==Clinical Features==
	*Delirium and global confusion		*[[Delirium]] and global confusion
	*Agitation		*[[Agitation]]
	*Autonomic hyperactivity		*Autonomic hyperactivity
	**Diaphoresis, tachycardia, tachypnea, hypertension, hyperthermia		**Diaphoresis, [[tachycardia]], [[tachypnea]], [[hypertension]], [[hyperthermia]]

	==Differential Diagnosis==		==Differential Diagnosis==
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	**CBC		**CBC
	**Metabolic panel		**Metabolic panel
	**LFTs		**[[LFTs]]
	**CK		**CK
	**Drug screen if concern for coingestion		**Drug screen if concern for coingestion
	*Imaging:		*Imaging:
	**CXR in all patients (pneumonia is most common infection)		**[[CXR]] in all patients (pneumonia is most common infection)
	**Consider [[head CT]] if evidence of head trauma, focal deficits, or other concerning findings		**Consider [[head CT]] if evidence of head trauma, focal deficits, or other concerning findings
	**Consider LP if concern for meningitis		**Consider [[LP]] if concern for meningitis

	==Management==		==Management==

Rossdonaldson1: /* Management */

2017-11-07T23:11:17Z

Management

← Older revision		Revision as of 23:11, 7 November 2017
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	***Phenobarbital 65mg → 130mg → 260mg IV		***Phenobarbital 65mg → 130mg → 260mg IV
	**If still agitated after phenobarbital → intubate and sedate with [[propofol]] and [[fentanyl]]		**If still agitated after phenobarbital → intubate and sedate with [[propofol]] and [[fentanyl]]
	*[[Thiamine]] 100mg
	*[[Magnesium]], [[folate]], [[dextrose]]-containing IVF		{{Vitamin prophylaxis for ETOH}}
	*[[Vitamin ~~B12]]~~

	===Special Situations===		===Special Situations===

Rossdonaldson1: Rossdonaldson1 moved page Delerium tremens to Delirium tremens over redirect

2017-02-14T21:37:07Z

Rossdonaldson1 moved page Delerium tremens to Delirium tremens over redirect

← Older revision	Revision as of 21:37, 14 February 2017
(No difference)

ClaireLewis: /* Management */

2016-12-24T16:57:36Z

Management

← Older revision		Revision as of 16:57, 24 December 2016
Line 31:		Line 31:
	==Management==		==Management==
	*Goal = sleepy but arousable with HR <110		*Goal = sleepy but arousable with HR <110
	*Escalating doses of benzodiazepines and phenobarbital<ref>Gold JA et al. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. 2007 Mar;35(3):724-30.</ref>		*Escalating doses of [[benzodiazepines]] and [[phenobarbital]]<ref>Gold JA et al. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. 2007 Mar;35(3):724-30.</ref>
	**Diazepam IV pushes q5-10 min		**[[Diazepam]] IV pushes q5-10 min
	**10mg x2 → 20mg x3 → 40mg x3 = 200mg total diazepam		**10mg x2 → 20mg x3 → 40mg x3 = 200mg total diazepam
	**If still agitated/hyperdynamic after 200mg of diazepam:		**If still agitated/hyperdynamic after 200mg of diazepam:

Mholtz at 07:55, 24 December 2016

2016-12-24T07:55:57Z

← Older revision		Revision as of 07:55, 24 December 2016
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	==Background==		==Background==
	*Onset after last drink ~~- 48 to 96hrs~~		*Most severe form of alcohol withdrawal
			*Onset 48 to 96hrs after last drink

	==Clinical Features==		==Clinical Features==

Mholtz at 07:55, 24 December 2016

2016-12-24T07:55:17Z

← Older revision		Revision as of 07:55, 24 December 2016
Line 3:		Line 3:

	==Clinical Features==		==Clinical Features==
	*Delirium		*Delirium and global confusion
	**~~Disconnected from the environment~~		*Agitation
	*~~Hyperdynamic vital signs~~		*Autonomic hyperactivity
	*~~Febrile~~		**Diaphoresis, tachycardia, tachypnea, hypertension, hyperthermia

	==Differential Diagnosis==		==Differential Diagnosis==
Line 14:		Line 14:

	==Evaluation==		==Evaluation==
	*Consider [[head CT]]		*Generally a clinical diagnosis, however comorbidity is common so additional work-up/screening is required:
	*Consider ~~infectious workup, to include~~ LP		*Labs:
			**Serum glucose
			**Serum ethanol
			**CBC
			**Metabolic panel
			**LFTs
			**CK
			**Drug screen if concern for coingestion
			*Imaging:
			**CXR in all patients (pneumonia is most common infection)
			**Consider [[head CT]] if evidence of head trauma, focal deficits, or other concerning findings
			**Consider LP if concern for meningitis

	==Management==		==Management==
	*Goal = sleepy, but arousable with HR <110		*Goal = sleepy but arousable with HR <110
	*[[Diazepam]]
	**Long duration of action, max effect within 5min
	**Start 10mg IV
	***Redose q5min after observing effect
	***Can double subsequent doses until achieve goal
	*Escalating doses of benzodiazepines and phenobarbital<ref>Gold JA et al. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. 2007 Mar;35(3):724-30.</ref>		*Escalating doses of benzodiazepines and phenobarbital<ref>Gold JA et al. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. 2007 Mar;35(3):724-30.</ref>
	**Diazepam IV pushes q5-10 min		**Diazepam IV pushes q5-10 min
	**10mg x2 ~~-->~~ 20mg x3 ~~-->~~ 40mg x3 = 200mg total diazepam		**10mg x2 → 20mg x3 → 40mg x3 = 200mg total diazepam
	**If still agitated/hyperdynamic after 200mg of diazepam:		**If still agitated/hyperdynamic after 200mg of diazepam:
	***[[Phenobarbital]] IV push q5-10min, x3 escalating doses		***[[Phenobarbital]] IV push q5-10min, x3 escalating doses
	***Phenobarbital ~~65 --> 130 -->~~ 260mg IV		***Phenobarbital 65mg → 130mg → 260mg IV
	**If still agitated after ~~phenobarb, intubation~~ with [[propofol]] and [[fentanyl]]		**If still agitated after phenobarbital → intubate and sedate with [[propofol]] and [[fentanyl]]
	*[[Thiamine]] 100mg		*[[Thiamine]] 100mg
	*[[Magnesium]], [[folate]], [[dextrose]] ~~IVFs~~		*[[Magnesium]], [[folate]], [[dextrose]]-containing IVF
	*[[Vitamin B12]]		*[[Vitamin B12]]

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	<references/>		<references/>

	[[Category:~~Psychiatry~~]][[Category:~~Toxicology~~]]		[[Category:Toxicology]]
			[[Category:Psychiatry]]

ClaireLewis: /* Management */

2016-12-22T22:53:19Z

Management

← Older revision		Revision as of 22:53, 22 December 2016
Line 28:		Line 28:
	**10mg x2 --> 20mg x3 --> 40mg x3 = 200mg total diazepam		**10mg x2 --> 20mg x3 --> 40mg x3 = 200mg total diazepam
	**If still agitated/hyperdynamic after 200mg of diazepam:		**If still agitated/hyperdynamic after 200mg of diazepam:
	***Phenobarbital IV push q5-10min, x3 escalating doses		***[[Phenobarbital]] IV push q5-10min, x3 escalating doses
	***Phenobarbital 65 --> 130 --> 260mg IV		***Phenobarbital 65 --> 130 --> 260mg IV
	**If still agitated after phenobarb, intubation with [[propofol]] and [[fentanyl]]		**If still agitated after phenobarb, intubation with [[propofol]] and [[fentanyl]]
	*[[Thiamine]] 100mg		*[[Thiamine]] 100mg
	*Magnesium, folate, dextrose IVFs		*[[Magnesium]], [[folate]], [[dextrose]] IVFs
	*B12		*[[Vitamin B12]]

	===Special Situations===		===Special Situations===