Delirium tremens

Background

• Onset after last drink - 48 to 96hrs

Clinical Features

• Delirium
  • Disconnected from the environment
• Hyperdynamic vital signs
• Febrile

Differential Diagnosis

Altered mental status

Diffuse brain dysfunction

• Hypoxic encephalopathy
• Acute toxic-metabolic encephalopathy (Delirium)
  • Hypoglycemia
  • Hyperosmolar state (e.g., hyperglycemia)
  • Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
  • Organ system failure
  • Hepatic Encephalopathy
  • Uremia/Renal Failure
  • Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
  • Hypoxia
  • CO2 narcosis
• Hypertensive Encephalopathy
• Toxins
• TTP / Thrombotic thrombocytopenic purpura
• Alcohol withdrawal
• Drug reactions (NMS, Serotonin Syndrome)
• Environmental causes
  • Hypothermia
  • Hyperthermia
• Deficiency state
  • Wernicke encephalopathy
  • Subacute Combined Degeneration of Spinal Cord (B12 deficiency)
  • Vitamin D Deficiency
  • Zinc Deficiency
• Sepsis
• Osmotic demyelination syndrome (central pontine myelinolysis)
• Limbic encephalitis

Primary CNS disease or trauma

• Direct CNS trauma
  • Diffuse axonal injury
  • Subdural/epidural hematoma
• Vascular disease
  • Intraparenchymal hemorrhage
• SAH
• Stroke
  • Hemispheric, brainstem
• CNS infections
  • Encephalitis
  • Anti-NMDA receptor encephalitis
  • Meningitis
• Neoplasms
  • Paraneoplastic Limbic encephalitis
  • Malignant Meningitis
  • Pancreatic Insulinoma
• Seizures
  • Nonconvulsive status epilepticus
  • Postictal state
• Dementia
  • Alzheimer's
  • Lewy Body Dementia
  • Frontotemporal Dementia

Psychiatric

• Acute psychosis
• Catatonia
• Excited delirium
• Malingering
• Steroid induced psychosis

General Psychiatric

• Organic causes
  • Delirium
  • Dementia
  • Overdose
• Psychiatric causes
  • Depression
  • Anxiety
  • Conversion disorder
  • Bipolar disorder
  • Acute psychosis
  • Panic attack
  • Schizophrenia

Management

• Goal = sleepy, but arousable w/ 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
• Propofol
  • Consider intubation + propofol drip if benzo-nonresponsive
• Thiamine 100mg

Disposition

Admit

See Also

• Beer Potomania Syndrome
• Alcohol (ETOH) Intoxication
• Alcoholic ketoacidosis
• Alcohol withdrawal
• Alcohol withdrawal: Inpatient management
• Alcohol withdrawal: Outpatient management
• Alcohol withdrawal seizures
• Altered mental status
• Delerium tremens
• EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal
• Sedative/Hypnotic
• Wernicke-Korsakoff Syndrome