Cite this post as:
Scott Weingart, MD FCCM. EMCrit Podcast 11 – Delirium Tremens. EMCrit Blog. Published on September 29, 2009. Accessed on November 30th 2021. Available at [https://emcrit.org/emcrit/delirium-tremens/ ].
Financial Disclosures
Unless otherwise noted at the top of the post, the speaker(s) and related parties have no relevant financial disclosures.
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roc on.
Hey!
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
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.
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,… Read more »
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.
Scott,
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?
MJP
Matt-
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.
scott
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.
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.
What do you think about precedex drips? Our ICU docs prefer this it seems.
We have no evidence that this really effects the underlying problems of DTs rather than just making the vital signs better.
Thank you for the reply… my friend really wanted to know!
Hi Scott,
My ICU attending argued that giving too much diazepam make patient turn acidosis from proprylene glycol. What’s your take on this?
Thanks!
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… Read more »
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.
I used this protocol Sunday night 3/28/2021. At 200 mg of Valium, I pivoted to 260 mg phenobarbital. This worked very well and I avoided ICU, intubation, Precedex drip. It was very labor intense. I would load him up with valium, get to a RASS score of -1 or -2. I thought I was done but 90 minutes later, he’ was crawling out of bed screaming. I’d load him up with 2 or 3 doses of 20 mg and he’d be fine in minutes. 90 minutes later, I’d be back in the room. I loaded him with the 40’s and… Read more »
sweet!! At this stage, I pretty much go straight to escalating doses of phenobarb