What is the optimal management of delirium tremens in an adult presenting with acute alcohol withdrawal, agitation, autonomic hyperactivity, and hallucinations?

Delirium Tremens Management

Benzodiazepines are the definitive first-line treatment for delirium tremens and must be initiated urgently to prevent mortality, with diazepam or lorazepam administered intravenously in escalating doses until symptom control is achieved. 1, 2

Immediate Pharmacologic Management

Benzodiazepine Administration:

• Administer diazepam 10 mg IV initially, then 5-10 mg IV every 3-4 hours as needed for ongoing agitation, tremor, or hallucinations. 3 In severe cases requiring very high doses, diazepam 260-480 mg/day has been successfully used without morbidity. 4
• Alternatively, lorazepam can be used, particularly in patients with liver disease, as it lacks active metabolites. 2
• Symptom-triggered dosing targeting specific manifestations (agitation, psychosis, autonomic hyperactivity) decreases severity, duration, and total medication requirements compared to fixed-schedule dosing. 5

Critical Distinction:

• Do NOT use dexmedetomidine as a sedative in alcohol withdrawal delirium—benzodiazepines remain the only appropriate sedative for this condition. 5, 1 This is explicitly stated in Critical Care Medicine guidelines, as dexmedetomidine is only preferred over benzodiazepines for delirium unrelated to alcohol or benzodiazepine withdrawal. 5

Adjunctive Therapies

Antipsychotics (Use with Extreme Caution):

• Haloperidol may be added ONLY for severe agitation or hallucinations refractory to adequate benzodiazepine dosing, and ONLY after benzodiazepines are on board. 1, 6 Antipsychotics should never be first-line, as they can worsen outcomes and mask withdrawal symptoms. 6
• Check baseline QTc interval before any antipsychotic administration—avoid in patients with QTc prolongation, concurrent QT-prolonging medications, or history of torsades de pointes. 5, 1

Benzodiazepine-Refractory Cases:

• For cases requiring mechanical ventilation despite high-dose benzodiazepines, dexmedetomidine may be used as adjunctive therapy (not replacement) to reduce sympathetic hyperactivity and facilitate weaning. 6, 7
• Propofol infusion (mean 4.22 mg/kg/h) can be used for refractory delirium tremens requiring intubation and mechanical ventilation, though this requires ICU-level care and carries risk of prolonged sedation. 8, 2, 9
• Phenobarbital is another option for benzodiazepine-refractory cases. 2

Essential Supportive Care

Thiamine Administration:

• Administer thiamine 100-300 mg IV immediately and daily to prevent irreversible Wernicke encephalopathy—this is a medical emergency that must be addressed before glucose administration. 1, 6

Monitoring Requirements:

• Monitor vital signs continuously, as delirium duration correlates with 10% increased mortality risk per day. 5, 1
• Use CIWA-Ar scale to quantify withdrawal severity; scores ≥15 indicate severe withdrawal requiring intensive monitoring. 1
• Screen for concurrent infections (spontaneous bacterial peritonitis, cholangitis, aspiration pneumonia) that commonly complicate alcohol withdrawal. 1

Critical Pitfalls to Avoid

Medication Safety:

• Never abruptly discontinue benzodiazepines after prolonged use (>7-10 days)—taper over several days to prevent withdrawal seizures. 5, 1
• Avoid lorazepam continuous infusions due to propylene glycol toxicity risk; use intermittent boluses instead. 10
• Do NOT use rivastigmine—it increases delirium severity and mortality. 5, 10

Treatment Errors:

• Do not use antipsychotics as first-line treatment—they provide no benefit for alcohol withdrawal and can worsen outcomes. 6
• Do not withhold adequate benzodiazepine doses due to fear of respiratory depression—undertreating delirium tremens carries higher mortality risk than appropriate sedation. 1, 2
• Ensure respiratory support is readily available when administering IV benzodiazepines. 3

Administration Technique

IV Diazepam Specifics:

• Inject slowly, taking at least one minute for each 5 mg given. 3
• Avoid small veins (dorsum of hand/wrist) and take extreme care to avoid intra-arterial administration or extravasation. 3
• Do not mix or dilute with other solutions in syringe or infusion container. 3