Treatment of Delirium Tremens (DT's)
Benzodiazepines are the gold standard first-line treatment for delirium tremens, with intravenous diazepam 10 mg initially followed by 5-10 mg every 3-4 hours as the preferred approach, combined with immediate thiamine 100-500 mg IV before any glucose administration. 1, 2
Primary Pharmacological Management
Benzodiazepine Therapy (First-Line)
Diazepam is the preferred agent due to its rapid onset when given intravenously and superior protection against seizures and delirium tremens compared to shorter-acting agents 3, 1, 4, 5
Initial dosing: Start with 10 mg IV, then administer 5-10 mg every 3-4 hours until symptom control is achieved 1
High-dose requirements: Some patients with severe DT following prolonged heavy alcohol use may require very high doses (260-480 mg/day) to achieve symptom control 5
Alternative benzodiazepine: Switch to lorazepam 6-12 mg/day if the patient has hepatic dysfunction, advanced age, or obesity, as lorazepam has no active metabolites and shorter half-life 1, 6, 7
Chlordiazepoxide 50-100 mg orally followed by 25-100 mg every 4-6 hours (maximum 300 mg in first 24 hours) can be used for moderate to severe withdrawal in patients without liver disease 6
Critical Thiamine Administration
Administer thiamine 100-500 mg IV immediately BEFORE any glucose-containing fluids to prevent precipitating Wernicke encephalopathy 3, 1, 6
Continue thiamine 100-300 mg/day for 2-3 months following resolution 1
Antipsychotic Use (Adjunctive Only)
Do NOT use antipsychotics as first-line treatment - recent evidence shows they provide no benefit in mild-to-moderate delirium and may worsen symptoms 1
Haloperidol 0.5-2 mg IV may be added ONLY for distressing hallucinations or severe agitation that persists despite optimized benzodiazepine therapy and threatens patient/staff safety 3, 1, 8
Discontinue antipsychotics immediately once distressful symptoms resolve 3
Avoid in patients at risk for torsades de pointes (baseline QTc prolongation, concomitant QTc-prolonging medications, or history of this arrhythmia) 9
Essential Supportive Care
Fluid and Electrolyte Management
Aggressive fluid replacement with careful attention to commonly depleted electrolytes in chronic alcohol use 1
Monitor and correct hypomagnesemia, hypokalemia, and hypophosphatemia, as these imbalances worsen delirium 3, 1
Correct dehydration and hypo/hyperglycemia 3
Monitoring Requirements
Manage in ICU or ward with continuous vital signs monitoring due to risk of malignant arrhythmia, respiratory arrest, sepsis, severe electrolyte disturbance, or prolonged seizures 7
Use objective bedside delirium instruments for routine monitoring 9
Non-Pharmacological Interventions
Provide quiet room with visible calendars and clocks 3
Maintain caregiver consistency 3
Optimize environment by controlling light and noise, clustering patient care activities, and decreasing nighttime stimuli to protect sleep cycles 9, 3
Alternative Agents (When Benzodiazepines Contraindicated)
Carbamazepine 200 mg every 6-8 hours is effective for seizure prevention if benzodiazepines cannot be used 6
Dexmedetomidine may help when agitation precludes weaning from mechanical ventilation 9, 3
In benzodiazepine-refractory cases, phenobarbital, propofol, or dexmedetomidine can be considered 4
Post-Acute Management
Psychiatric consultation is mandatory after stabilization for ongoing treatment planning and long-term abstinence strategies 1
Consider relapse prevention medications such as acamprosate, naltrexone, baclofen, or topiramate after the acute withdrawal phase (not useful during active withdrawal) 3, 1, 6
Avoid disulfiram in patients with liver disease due to hepatotoxicity risk 3
Critical Pitfalls to Avoid
Never administer glucose-containing fluids before thiamine - this can precipitate acute Wernicke encephalopathy 1, 6
Do not use anticonvulsants alone for alcohol withdrawal seizures - benzodiazepines are required 6
Do not substitute gabapentin for benzodiazepines in moderate to severe withdrawal, as this results in inadequate symptom control and increased risk of seizures and DT 6
Recognize that prior alcohol dependence is often underestimated in ICU patients, making identification of at-risk patients difficult 9