Alcohol Withdrawal Delirium (Delirium Tremens)

Alcohol withdrawal delirium should be treated as a medical emergency as it has a mortality rate of up to 4%. If the patient does not respond to early treatment, management may need to occur in a highly monitored environment such as an intensive care or a high-dependency unit. Furthermore, the degree of sedation required for treatment of alcohol withdrawal delirium can be high and you should seek early input from your senior colleagues.

Key priorities:

• Control acute confusional state
• Prevent further deterioration
• Prevent Wernicke’s encephalopathy
• Provide a safe environment for patient to prevent harm to self and others

Investigations

• Blood glucose concentration – to rule out hypoglycemia (acute onset confusion)
• U&E –
• LFT – GGT → alcohol damage, also to rule out hypoglycemia, hyponatremia, and encephalopathy due to renal/liver failure
• FBC – Macrocytosis → consistent with longstanding Alcohol use disorder BUT broad DDx
  • Alcohol
  • Medicines
  • Nutritional deficiencies
  • Liver disease
• Septic screen: blood & urine cultures and CXR – LP to exclude meningitis or encephalitis should be considered in correct clinical scenario
• Urine Drug Screen – may be helpful if drug intoxication suspected
• CT brain/skull – if trauma or SOL suspected

Management

• Nonpharmacological
  • Low stimulus environment i.e. quiet room (however with intensive monitoring if possible)
  • Initiate alcohol withdrawal scale
• Pharmacological
  • Thiamine 300 mg parenterally for 3-5 days once daily, then
  • Thiamine 100 mg PO thrice daily for 1-2 weeks, then 100 mg once daily PO for a few months if abstinent or indefinitely if he continues to drink

    • People who consume large amounts of alcohol are at high risk of thiamine deficiency. A life-threatening complication of thiamine deficiency is Wernicke’s encephalopathy (opthalmoplegia, ataxia and confusion), which can progress to Korsakoff syndrome. Intramuscular or intravenous administration of thiamine is important in the acute management of alcohol withdrawal. The other vitamins can be supplemented if needed as part of holistic assessment of nutritional status.

  • Diazepam 10-20 mg PO 2 hourly for a maximum of 60 mg per day, PRN
    • Parenteral same onset of action as oral, but more risks i.e. sedation, thrombophlebitis

      • Diazepam is the recommended first-line medicine for the management of alcohol withdrawal. It has a rapid onset of action after oral administration and has a long half-life.

        Although midazolam is also a benzodiazepine, it is too short-acting to be useful in this setting. An antipsychotic medicine is sometimes used to relieve psychotic symptoms that have not resolved with use of diazepam. In this instance, haloperidol is preferred.

      • One of the most dangerous adverse effects of benzodiazepine use is central nervous system depression. This can be monitored by regularly assessing the patient’s sedation score and respiratory rate. A patient who is not easily rousable is in danger of respiratory depression and intervention is required.

        Benzodiazepine use can cause hypotension, which increases the patient’s risk of falls and subsequent harm. Monitoring blood pressure and use of bed rails can be helpful in this situation.

        In certain situations, benzodiazepine use can be reversed through the use of flumazenil. The half-life of flumazenil is very short, so repeated administration may be required. In susceptible people, flumazenil administration may precipitate seizures and withdrawal syndrome, so specialist advice should be sought

  • Antipsychotics – if hallucinations don’t respond to diazepam

Monitoring withdrawal symptoms

• Body temp – sweating + temp + increased pulse rate
• Sedation score – assess therapeutic AND adverse effects of diazepam, monitor and aim for sedation score of <2
• Low scre on AWS – if treatment successful → patient agitation should settle; guage by checking AWS

Communicating with the GP

• documentation of patient’s history of alcohol use and, if possible, quantification of the amount consumed and for how long
• the presentation of patient’s symptoms and their timing in relation to his admission and subsequent abstinence from alcohol
• acute management of the episode (calm environment with minimal stimuli, prescription of diazepam and thiamine)
• patient’s response to treatment using an alcohol withdrawal scale and reduction in symptoms
• if applicable, patient’s readiness to abstain from alcohol.