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Delirium Tremens: Follow-up

Author: Michael James Burns, MD, FACEP, FACP, Health Science Clinical Professor, Department of Emergency Medicine, Department of Internal Medicine, Division of Infectious Diseases, University of California Irvine School of Medicine
Coauthor(s): James B Price, MD, Attending Emergency Physician, Mission Hospital; Clinical Faculty, Department of Emergency Medicine, Harbor-UCLA Medical Center; Michael E Lekawa, MD, FACS, Associate Clinical Professor of Surgery, University of California, Irvine School of Medicine; Chief, Department of Surgery, Division of Trauma and Critical Care, Director of Trauma Services, Director of Surgical Intensive Care Unit, Director of Student Critical Care Teaching Program, Medical Director of Surgery Clinics, University of California, Irvine Medical Center
Contributor Information and Disclosures

Updated: Nov 9, 2009

Follow-up

Further Inpatient Care

• Indications for hospital admission of a patient with alcohol withdrawal syndrome include delirium tremens (DTs); severe symptoms such as hallucinations, disorientation, confusion, autonomic hyperactivity, or extreme agitation; the presence of a medical or surgical condition requiring treatment; a recent history of head injury with loss of consciousness; recurrent seizures; partial seizures; or focal neurologic findings upon examination.
• Once patients with DTs have been stabilized, further dosing with benzodiazepines is needed to manage their alcohol withdrawal. A symptom-triggered dosing regimen, rather than fixed-schedule dosing, is the current preferred regimen. Fixed-dose regimens often result in excessive sedation.
• Alcohol withdrawal seizures are generalized and usually only occur once or recur only once or twice, and these seizures generally resolve spontaneously. If a patient has a seizure that is not typical of an alcohol withdrawal seizure (such as a partial or focal seizure, prolonged seizures, or prolonged post-ictal state), or has signs of significant head trauma, then the underlying cause of the seizure should be investigated. Alcohol-dependent patients have increased rates of idiopathic epilepsy, traumatic brain injury, stroke, and intracranial mass lesions. Moreover, seizures in alcohol-dependent patients may be caused by concomitant use of stimulant drugs such as cocaine or amphetamines, or by withdrawal from sedative agents such as benzodiazepines or barbiturates.   
• The use of benzodiazepines has been shown to prevent initial and recurrent seizures. Phenytoin is not indicated for the prophylaxis or treatment of these seizures. A Cochrane systematic review concluded that clinical trials have not shown a benefit for anticonvulsant therapy in treatment of alcohol withdrawal syndrome, but because of the heterogeneity of the trials both in interventions and assessment of outcomes, definite conclusions about their safety and effectiveness cannot be made.
• Using the Revised Clinical Institute for Withdrawal Assessment for Alcohol (CIWA-Ar) scale may not be appropriate for guiding symptom-triggered therapy in patients who have complex medical problems or who are postsurgical, critically ill, or in intensive care units. Studies demonstrating the effectiveness of the CIWA-Ar scale in safely managing alcohol withdrawal were performed in medically stable ward patients. Patients with complex medical issues, postsurgical patients, intensive care unit patients, and critically ill patients were generally excluded from these trials. The CIWA-Ar scale has not been validated in these patients. 
• Moreover, the CIWA-Ar protocol and symptom-triggered therapy has been applied inappropriately to patients who had not been drinking for many weeks and who were not able to communicate, resulting in misdiagnosis and delayed diagnosis of other causes of delirium, as well as severe benzodiazepine intoxication due to inappropriate medication use. Postoperative delirium, for which there are many etiologies, has been misdiagnosed as alcohol withdrawal and the CIWA-Ar applied inappropriately with subsequent mistreatment. Patients with complicated medical and surgical comorbidities are not appropriate candidates for symptom-triggered therapy guided by the CIWA-Ar scale. 
• In critically ill patients in intensive care units, symptom-triggered benzodiazepine therapy using very high-dose bolus therapy has been associated with a reduction in the need for mechanical ventilation. The institution of a guideline for intensive care unit patients felt to have "benzodiazepine-refractory" alcohol withdrawal that maximized the bolus dose of benzodiazepine with addition of phenobarbital if necessary, with doses determined by score on the Riker Sedation Analgesia Scale, lead to a reduction in mechanical ventilation with a trend toward reduction in length of stay and nosocomial infection. Single intravenous bolus doses of diazepam of 100-200 mg may be required. 
• Intravenous ethanol infusions have been used in the past, especially in surgical intensive care units, as prophylaxis against alcohol withdrawal among patients with suspected or proven alcohol dependence. Retrospective, uncontrolled, noncomparative case series have reported both successful and unsuccessful use of intravenous ethanol in trauma and burn patients. Comparative or randomized studies have not demonstrated efficacy for this treatment, and this treatment was inferior to diazepam in a prospective, randomized trial.⁶  As intravenous ethanol has a short duration of action, narrow margin of safety, has toxic effects on gastric mucosa, pancreas, liver, bone marrow and other organs, and requires considerable volumes of fluids for administration, this treatment cannot be recommended.

Further Outpatient Care

• The issue of alcohol dependence should be addressed prior to hospital discharge because detoxification from alcohol in the hospital is not sufficient to prevent a return to hazardous alcohol use. Treatment to prevent relapse frequently requires extended management over long periods of time.     
• Alcohol cessation programs and support groups, such as Alcoholics Anonymous, should be recommended. 
• Pharmacological aids to alcohol cessation should be considered because they may prevent relapse in patients who have been treated for alcohol dependence. Disulfiram, naltrexone, acamprosate, and topiramate have been used in the long-term treatment of alcohol dependence and are initiated after detoxification to alcohol has been completed.
• Cognitive behavioral therapy and motivational enhancement therapy (which are sometimes combined with pharmacological therapy) have been used successfully to prevent relapse.
• To prevent hazardous alcohol use, routine screening for alcohol use should be performed in primary care settings. The use of the CAGE questionnaire or the Alcohol Use Disorders Identification Test (AUDIT) questionnaire is useful in screening.
• Protocols for screening persons at risk for hazardous alcohol use, followed by brief intervention (5-10 minutes) carried out by clinicians, nurses, or social workers, have been shown to result in a reduction in alcohol consumption and alcohol-related injuries and decreased readmissions to the emergency department. Computer-based screening and counseling programs may be useful when clinicians do not have time to perform screening and face-to-face intervention.

Miscellaneous

Medicolegal Pitfalls

• Failure to consider the diagnosis of alcohol withdrawal syndrome in patients with altered mental status or abnormal vital signs is a potential pitfall.
• Failure to treat patients with severe alcohol withdrawal syndrome with adequate doses of benzodiazepines is a potential pitfall because these patients may require extremely large doses of parenteral benzodiazepines.
• Making the assumption that all seizures in people with alcoholism are due to alcohol withdrawal without considering other causes of seizures, such as infection, hemorrhage, or trauma, is a potential pitfall.
• Failure to exclude other etiologies of altered mental status in patients with suspected alcohol withdrawal is a potential pitfall.
• Failure to admit patients to the hospital with signs and symptoms of major withdrawal or delirium tremens (DTs) is a potential pitfall.
• Use of a sympatholytic drug (ie, clonidine, atenolol) alone or with inadequate doses of benzodiazepines can potentially cause problems because use of these drugs provides a false sense of security by correcting some of the autonomic manifestations of withdrawal in a patient who may be progressing to DTs. Sympatholytic drugs should not be administered unless adequate doses of benzodiazepines also are administered.
• Use of phenytoin to prevent or treat alcohol withdrawal seizures is not recommended. Phenytoin is not effective in preventing or treating alcohol withdrawal seizures. Seizures due to alcohol withdrawal are best prevented and treated with benzodiazepines.
• Use of neuroleptic drugs (phenothiazines, butyrophenones) alone to treat agitation or hallucinations caused by alcohol withdrawal potentially can cause problems because these drugs are not effective in preventing or treating DTs and may increase the risk of seizures. Use of a small dose of a butyrophenone, such as haloperidol, may be useful as adjunctive therapy to treat agitation and hallucinations, as long as adequate doses of benzodiazepines have been administered.
• The use of alcohol to prevent or treat alcohol withdrawal and DTs is not recommended. Alcohol has multiple toxicities, including pancreatitis, hepatitis, cardiomyopathy, gastritis, and bone marrow suppression. It also has a short half-life and requires monitoring of blood levels when used intravenously, and its use may appear to condone alcohol intake in the patient with alcoholism who is beginning recovery. Alcohol treatment has not been shown in controlled trials to be effective in preventing seizures or DTs.

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