Morning Report

Morning Report: 10/31/2014

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Here’s Dr. Ammon with a great Halloween edition of Morning Report!

 

DELIRIUM TREMENS

Most severe form of alcohol withdrawl manifested by AMS (global confusion) and sympathetic overdrive (autonomic hyperactivity).

 

CHRONIC ETOH -> CNS DEPESSANT -> ETOH-GABA -> inhibitory effect….

 

No ETOH -> OVERACTIVE CNS -> CARDIOVASCULAR COMPROMISE…

Hallucinations, disorientation, tachycardia, hypertension, fever, agitation

 

ED MANAGEMENT, GOAL –> target HR <120

  1. ABC, IV, O2, Monitor
  2. 1ST LINE: Benzodiazepines: diazepam 5-10mg IV q5-10mins; lorazepam 2-4mg IV q15-20mins.

 

Refractory DT: more than 50mg diazepam or 10mg Ativan used within first hour or you reached 200mg diazepam or 40mg lorazepam.

 

2nd LINE: 1. phenobarbital IV repeated 15-20mins 2.Intubate, give Propofol and fentanyl

 

DT PROTOCOL

VALIUM IV Q5-10minutes

10 -> 10 ->20 -> 20 -> 20 -> 40 -> 40 -> 40 …… Patient still agitated?

———————————————————————————————-

  1. Phenobarital IV 65 -> 130 -> 260….. OR
  2. Intubate and start Propofol and Fentanyl drips

 

Medication Profiles:

Valium: <1min, elimination 20-50 hrs side effects: respiratory sedation, hypotension,

Ativan: onset 3-10, elimination 3-11 hrs, side effects: met acidosis (propylene glycol toxicity). Dosing 1-4mg bolus

Propofol: onset <1min, side effects: hypotension, hyperlipidemia, and propofol related infusion syndrome. Dosing: initial bolus 0.25-1.0mg/kg , infusion 5-80mcg/kg/min

Phenobarbital: onset <5mins. Elimination 53-140hrs. Side effects hypotension, sedation, hypoventilation. Dosing 100-320mg, max 600mg daily.

 

PEARLS:

  • Be Aggressive, may require bigger dose of benzos than you’re used to, up to 200-300mg
  • Target the HR in your management
  • Higher mortality rates associated with electrolye and metabolic derangements

 

References:

  1. Em Crit podcast 11, EMRAP podcast Nov 2011
  2. Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med 2004; 164:1405.
  3. DeBellis R, Smith BS, Choi S, Malloy M. Management of delirium tremens. J Intensive Care Med 2005; 20:164.
  4. Amato L, Minozzi S, Vecchi S, Davoli M. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev 2010; :CD005063.
  5. McCowan C, Marik P. Refractory delirium tremens treated with propofol: a case series. Crit Care Med 2000; 28:1781.
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital
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