EMCrit Podcast 11 – Delirium Tremens


drinky_crowThe management of severe ETOH withdrawal and Delirium Tremens:

1. Consider alternative diagnoses

Here is my DT protocol

2. Start treatment with diazepam

3. If you reach 200 mg, switch to phenobarb or intubate and give propofol

4. Your goal is to get your patient sleepy, but arousable with a HR<120

The citation for the CCM article is (Crit Care Med 2007;35:724)

I also discuss a listener email regarding succinylcholine and whether it causes increased oxygen consumption.

In short: Roc Rocks and Sux Sucks! (that one is for you Reub)



phenobarb for etoh withdrawal

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  1. gregor says

    Whats Your take on haloperidol for Delirium in general and DT specifically?
    Our Internists like Haloperidol + clometiazol (Distraneurin®)

    THX & keep up the GREAT work! Gregor, Slovenia

    • emcrit says

      For delerium, it’s great!
      for DTs it is deadly b/c it masks the symptoms without treating the cause. Of course, no true evidence for any of this. Dr. Goldfrank may say that with the management he has outlined, his hospitals mortality rates went from very high to virtually nil for this disease. Do with that what you will.

      • Rickhi says

        For DT’s I see many of my fellow colleagues give Ativan. It does not work. Diazepam is the gold standard along with thiamine. I typically load with 60mg . I do not use IV diazepam as you will lose the vein guaranteed. Diazepam works great as it has one of the longest half life’s of all all benzo’s. with DT’s you need to worry about day 3 where patients have a grand mal seizure with a 25% mortality rate. We can talk about Librium but if you look at the pharmacological curve if you will see you for yourself.

        Also, I feel compelled to point out a psych consult is a must in terms of screening for cormorbidities, and rehab etc..

        • says

          Ummmmm……. Ativan works fine, lot of prop glycol acidosis though. We have been using IV diazepam for about 20 years and the veins seem just swell.

  2. Matthew Pirotte says


    I like the valium idea in principle but isn’t that selecting a therapy on the assumption that your admitting services don’t know how to manage DTs? I guess my concern would be that we shouldn’t necessarily be giving one med over the other because we are hoping to prevent a mistake we don’t know will happen.

    Are there any other disease processes we approach like this?


    • emcrit says

      It is a valid point. However, even if you eliminate that consideration, diazepam is still the ideal agent b/c it lets you see it’s full effects in ~5 minutes after dosing. We have had stacking dose problems with lorazepam and of course midazolam is too short acting unless you start a drip.


  3. Greg says

    Used the protocol last night on a patient in severe DT’s. Worked like a charm. Ended up intubated on a propofol drip. Post intubation I actually pushed propofol until the heart rate and hemodynamics normalized. Took 400 mg IVP propofol to get there and then I started the drip.

    • says

      Sounds about right. I have found that once I get to 200 of valium, most of the patients wind up on propofol even if they stave it off for a few hours.

  4. JS says

    Hi Scott,

    My ICU attending argued that giving too much diazepam make patient turn acidosis from proprylene glycol. What’s your take on this?


  5. Argo says

    Can you explain what is difference between acute alcohol withdrawal and delirium tremens?
    By definition, acute alcohol withdrawal start as early as six to eight hours after an abrupt reduction in alcohol intake, It may include generalized hyperactivity, anxiety, tremor, sweating, nausea, retching, tachycardia, hypertension and mild pyrexia. Seizures may occur in the first 12 to 48 hours .Also, auditory and visual hallucinations may develop. On the other hand, Delirium tremens starts some 48 to 72 hours after cessation of drinking and is characterized by coarse tremor, agitation, fever, tachycardia, profound confusion, delusions and hallucinations.
    I didn’t have patients with alcohol withdrawal , could you please explain the difference in presentation?
    Thank you in advance.

    • says

      they are on the same continuum with DTs being a more severe form of withdrawal. In general once altered mental status and severe vital sign perturbations exist, we would call it DTs.

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