Treatment Protocol for Delirium Tremens
Benzodiazepines in high doses are the gold standard first-line treatment for delirium tremens, with diazepam and lorazepam being the preferred agents, and patients should be managed in an intensive care setting with continuous vital signs monitoring due to the life-threatening nature of this condition. 1, 2, 3
Initial Assessment and Monitoring
Admit all patients with delirium tremens to an ICU or monitored ward with continuous vital signs monitoring, as DT can result in death from malignant arrhythmia, respiratory arrest, sepsis, severe electrolyte disturbances, or prolonged seizures. 2
Assess for the characteristic features: severe alcohol withdrawal symptoms (tremor, sweating, hypertension, tachycardia) combined with delirium (clouded consciousness, disorientation, disturbed circadian rhythms, thought process disturbances, sensory disturbances including hallucinations), all fluctuating over time. 2
Evaluate for underlying medical comorbidities, particularly liver disease, which is very common in DT patients and will influence treatment choices and outcomes. 3
First-Line Pharmacological Treatment: Benzodiazepines
Administer benzodiazepines in supramaximal doses as the mainstay of treatment. 1, 2, 3
For patients without significant hepatic dysfunction: Use long-acting benzodiazepines like diazepam or chlordiazepoxide, which provide better protection against seizures and delirium. 1
For elderly patients or those with hepatic dysfunction: Use short or intermediate-acting benzodiazepines like lorazepam or oxazepam to reduce accumulation risk. 1, 5
- Lorazepam is preferred due to rapid onset, shorter duration of action, low accumulation risk, no major active metabolites, and predictable bioavailability via oral or intramuscular routes. 6
In Europe, clomethiazole is also used as an alternative treatment for alcohol withdrawal syndrome. 1, 2
Adjunctive Antipsychotic Treatment
Add antipsychotics only when psychotic symptoms (hallucinations, severe agitation) are present, always in combination with benzodiazepines, never as monotherapy. 5
For severe agitation with psychotic features: Use haloperidol as the first-line antipsychotic, particularly in ICU settings. 1, 6, 5
- Haloperidol can be administered via multiple routes, has fewer active metabolites, limited anticholinergic effects, and lower propensity for sedation or hypotension compared to other antipsychotics. 6
Alternative atypical antipsychotics with supporting data include risperidone and olanzapine, which have lower propensity for over-sedation and movement disorders. 6
Monitor closely for antipsychotic complications: neuroleptic malignant syndrome, QTc interval prolongation, extrapyramidal symptoms, and withdrawal seizures (as antipsychotics lower seizure threshold). 5
Benzodiazepine-Refractory Cases
For cases not controlled with benzodiazepines alone: Consider adding phenobarbital, propofol, or dexmedetomidine. 3
Lorazepam may be added for agitation refractory to high doses of neuroleptics, though therapeutic levels of neuroleptics should be present first to prevent paradoxical excitation. 1
Supportive Care
Provide comprehensive supportive therapy: adequate hydration, electrolyte correction, nutritional support, and reorientation strategies. 2, 3
Reduce or eliminate delirium-inducing medications (steroids, anticholinergics) as much as possible. 1
Maximize non-pharmacological interventions: reorientation, cognitive stimulation, sleep hygiene, creating a quiet environment with favorable day-night rhythm conditions. 1, 7
Critical Pitfalls to Avoid
Never use benzodiazepines alone without addressing underlying medical causes of delirium, as reversible precipitating factors must be identified and treated. 1
Do not use short-acting benzodiazepines in young patients without liver disease, as long-acting agents provide superior seizure and delirium protection. 1
Never use antipsychotics as monotherapy for DT—they must always be combined with benzodiazepines. 5
Do not underestimate dosing requirements: severe DT may require doses far exceeding typical ranges, and inadequate dosing can result in death. 4