Disorders of Consciousness
805
Adapted from Reference 17.
Treatment
The drugs of choice for treating alcohol withdrawal delirium are the
ben-
zodiazepines
(19), which mimic the CNS depressant effects of alcohol by
stimulating GABA receptors in the brain. An added benefit of benzodi-
azepines is protection against generalized seizures.
ICU REGIMEN:
For patients who require care in the ICU,
intravenous
lorazepam
is an appropriate choice for the management of DTs (19). For
initial control, give 2 – 4 mg IV every 5 – 10 minutes until the patient is
calm. Thereafter, administer IV lorazepam every 1 – 2 hours in a dose that
maintains calm (a dose of 2 – 4 mg should be sufficient in most cases).
After at least 24 hours of calm, the dose can be tapered to determine if the
delirium persists. It is important to taper benzodiazepines as soon as pos-
sible because they accumulate and can produce prolonged sedation and
a prolonged ICU stay. An additional concern with prolonged administra-
tion of IV lorazepam is
propylene glycol toxicity
(see page 605). For more
information on benzodiazepines, see Chapter 51.
THIAMINE:
The clinical manifestations of DTs can mask an acute
Wernicke’s encephalopathy that is precipitated by glucose infusions in IV
fluids, as described earlier. Therefore, thiamine supplementation is a stan-
dard practice during the treatment of DTs. The popular dose is 100 mg
daily, which can be given intravenously without harm.
Features
Onset after Last Drink
Duration
Early Withdrawal
6–8 hours
1–2 days
Anxiety
Tremulousness
Nausea
Generalized Seizures
6–48 hours
2–3 days
Hallucinations
12–48 hours
1–2 days
Visual
Auditory
Tactile
Delirium Tremens
48–96 hours
1–5 days
Fever
Tachycardia
Hypertension
Agitation
Delirium
Table 44.2
Clinical Features of Alcohol Withdrawal
