Alcohol withdrawal delirium (Delirium tremens)

F10.4

DESCRIPTION

Delirium typically occurs 2–3 days following cessation of prolonged alcohol intake, reaching a peak at around 5 days. However, some withdrawal symptoms, such as tremor, may start within 12 hours.

Typical clinical features include:

  • visual hallucinations,
  • delusions,
  • disorientation, fluctuating level of consciousness,
  • agitation,
  • tonic-clonic seizures – these do not generally need long term anticonvulsant therapy,
  • tachycardia, and
  • hypertension.

It is important to consider alternative diagnoses, especially true in cases with an atypical presentation.

Similar symptoms may occur following withdrawal from other sedative-hypnotic agents.

Mortality varies from 1–5%.

GENERAL MEASURES

  • See Delirium with perceptual disturbances.
  • Cardiac monitoring and oximetry should be used when administering large doses of benzodiazepines.
  • Assess for infections and other co-morbid conditions.
  • Ensure adequate hydration. Overhydration is a common error made in this setting.
  • Correct abnormalities of electrolytes.
  • Nutritional support.
  • Consider referring appropriate patients to a rehabilitation programme after recovery from delirium tremens.

MEDICINE TREATMENT

Administer medicine doses according to severity of symptoms. These patients may require high doses of benzodiazepines because of hepatic enzyme induction.

  • Benzodiazepines, e.g.:
  • Diazepam, slow IV, 10 mg (Not IM).
    • Repeat dose after 5–10 minutes if required.
    • If this dose is not sufficient, use 10 mg every 5–10 minutes for another 1–2 doses.
    • If patient is not yet sedated, continue with doses of 20 mg until this occurs. Usual initial dose is 10–20 mg, but up to 60 mg is occasionally required.

OR

Where intravenous access is not possible:

  • Clonazepam, IM, 2 mg as a single dose.
    • If no response, repeat dose after 60 minutes until patient is sedated.
    • Repeat dose regularly to maintain mild sedation.

LoEIII

OR

  • Lorazepam, IM, 1–4 mg every 30–60 minutes until patient is sedated.
    • Repeat dose regularly to maintain mild sedation.

LoEIII

Once patient is sedated, i.e. light somnolence, maintain mild sedation with:

  • Diazepam, oral, 5–20 mg.
    • Repeat dose regularly to maintain mild sedation

LoEIII

CAUTION

Benzodiazepines, especially diazepam IV, can cause respiratory depression.

Monitor patients closely as benzodiazepines can exacerbate an abnormal mental state or mask important neurological signs of deterioration.

See the note regarding benzodiazepines in Confusional states/Delirium.

Neuroleptic medicines, e.g. haloperidol, are associated with a reduced seizure threshold. Consider only for severe agitation and restlessness persisting after adequate doses of benzodiazepines.

  • Haloperidol, IV/IM, 0.5–5 mg.
    • Repeat after 4–8 hours as required to a maximum of 20 mg daily.

Once patient has responded and is able to take oral medication:

  • Haloperidol, oral, 0.75–5 mg 4–8 hourly.

LoEIII [58]

When administering glucose-containing fluids:

  • Thiamine, oral/IM, 300 mg daily.