Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Delirium Tremens (DTs) Workup

  • Author: Michael James Burns, MD, FACEP, FACP; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM  more...
 
Updated: Apr 14, 2016
 

Approach Considerations

Serum, imaging, and cerebrospinal fluid (CSF) studies are important in the assessment of patients with alcohol withdrawal. Moreover, routine screening for unhealthy alcohol use in patients admitted to the hospital can be used to detect patients who are at risk for developing alcohol withdrawal. The American College of Surgeons Committee on Trauma mandates routine screening for unhealthy alcohol use for level 1 and 2 trauma centers. Screening tools include the Alcohol Use Disorders Identification Test (AUDIT), AUDIT-C, and the CAGE screening test.

Next

Serum Chemistry Studies

Serum chemistry studies should include:

  • Sodium
  • Potassium
  • Chloride
  • Bicarbonate
  • Blood urea nitrogen (BUN)
  • Creatinine
  • Magnesium
  • Phosphorous
  • Liver function tests
  • Creatine phosphokinase - Some patients develop rhabdomyolysis
  • Lipase
  • Ketones
Previous
Next

Other Laboratory Studies

Serum ethanol concentration is important to assess, because patients who exhibit withdrawal while ethanol is still present in the serum are likely to have a more severe course. Additional laboratory tests include the following:

  • Serum glucose
  • Complete blood count with differential
  • Drug screen, if suspicion of drug use is present

Measure serum anticonvulsant levels if the patient is known or suspected to be taking anticonvulsant medication. Other studies that may be useful in certain patients include measurement of serum lactate, as well as serum osmolality, with calculation of the osmolal gap.

Previous
Next

Imaging Studies

About 50% of patients with delirium tremens (DTs) who present with fever will have an infection, pneumonia being most common. A chest radiograph should be obtained in all patients suspected of having DTs. If there is any suspicion of trauma or head injury, imaging of the cervical spine (plain radiography or CT scanning) and head CT scanning should be performed.

Computed tomography (CT) scanning of the head is performed selectively. Indications for a head CT scan include the following:

  • New-onset seizure
  • Seizures occurring over longer than a 6-hour period
  • More than 6 seizures
  • Focal seizures
  • Evidence of head trauma
  • Focal neurologic deficits
  • A prolonged postictal state
  • Deteriorating level of consciousness
Previous
Next

Lumbar Puncture

Patients with alcohol withdrawal syndrome who have had a seizure and continue to be obtunded should have a lumbar puncture if no signs of increased intracranial pressure are present. Some patients may not have the classic signs of meningitis, such as nuchal rigidity, and the cerebrospinal fluid (CSF) of these patients should be examined to rule out meningitis. CSF pleocytosis is often present after withdrawal seizures, even in the absence of infection or intracranial bleeding. However, CSF pleocytosis after seizures should not be attributed solely to the seizures without a search for a treatable infectious cause.

Even in the absence of seizures, perform lumbar puncture if any suspicion of meningitis exists (fever, lethargy, confusion, or headache). The absence of nuchal rigidity does not reliably rule out meningitis in these patients.

Previous
 
 
Contributor Information and Disclosures
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

Michael James Burns, MD, FACEP, FACP is a member of the following medical societies: Alpha Omega Alpha, American Geriatrics Society, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Phi Beta Kappa, Royal Society of Tropical Medicine and Hygiene, American College of Emergency Physicians, American College of Physicians, California Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

James B Price, MD Attending Emergency Physician, Mission Hospital; Clinical Faculty, Department of Emergency Medicine, Harbor-UCLA Medical Center

James B Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians

Disclosure: Nothing to disclose.

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

Michael E Lekawa, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease, Clinical and Translational Science and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine

Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM is a member of the following medical societies: American College of Chest Physicians, Association of University Anesthetists, European Society of Intensive Care Medicine, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Shock Society, Society of Critical Care Medicine

Disclosure: Received income in an amount equal to or greater than $250 from: Masimo<br/>Received honoraria from LiDCO Ltd for consulting; Received intellectual property rights from iNTELOMED for board membership; Received honoraria from Edwards Lifesciences for consulting; Received honoraria from Masimo, Inc for board membership.

Acknowledgements

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

William K Chiang, MD Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center

William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

William G Gossman, MD Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Consulting Staff, Department of Emergency Medicine, Creighton University Medical Center

William G Gossman, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

J Stephen Huff, MD Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Lisa Kirkland, MD, FACP, CNSP, MSHA Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital

Lisa Kirkland, MD, FACP, CNSP, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, and Society of Hospital Medicine

Disclosure: Nothing to disclose.

Harold L Manning, MD Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School

Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Sage W Wiener, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Assistant Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Anne Yim, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital and State University of New York Downstate Medical Center

Anne Yim, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

References
  1. Eyer F, Schuster T, Felgenhauer N, Pfab R, Strubel T, Saugel B. Risk assessment of moderate to severe alcohol withdrawal--predictors for seizures and delirium tremens in the course of withdrawal. Alcohol Alcohol. 2011 Jul-Aug. 46(4):427-33. [Medline].

  2. Kim DW, Kim HK, Bae EK, Park SH, Kim KK. Clinical predictors for delirium tremens in patients with alcohol withdrawal seizures. Am J Emerg Med. 2015 May. 33 (5):701-4. [Medline].

  3. Grant BF, Goldstein RB, Saha TD, Chou SP, Jung J, Zhang H, et al. Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015 Aug. 72 (8):757-66. [Medline].

  4. Chan GM, Hoffman RS, Gold JA, Whiteman PJ, Goldfrank LR, Nelson LS. Racial variations in the incidence of severe alcohol withdrawal. J Med Toxicol. 2009 Mar. 5(1):8-14. [Medline].

  5. Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989 Nov. 84(11):1353-7. [Medline].

  6. Watling SM, Fleming C, Casey P, Yanos J. Nursing-based protocol for treatment of alcohol withdrawal in the intensive care unit. Am J Crit Care. 1995 Jan. 4(1):66-70. [Medline].

  7. Reoux JP, Oreskovich MR. A comparison of two versions of the clinical institute withdrawal assessment for alcohol: the CIWA-Ar and CIWA-AD. Am J Addict. 2006 Jan-Feb. 15(1):85-93. [Medline].

  8. Khan BA, Guzman O, Campbell NL, Walroth T, Tricker J, Hui SL. Comparison and agreement between the Richmond Agitation-Sedation Scale and the Riker Sedation-Agitation Scale in evaluating patients' eligibility for delirium assessment in the ICU. Chest. 2012 Jul. 142(1):48-54. [Medline].

  9. Gold JA, Rimal B, Nolan A, Nelson LS. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. 2007 Mar. 35(3):724-30. [Medline]. [Full Text].

  10. Duby JJ, Berry AJ, Ghayyem P, Wilson MD, Cocanour CS. Alcohol withdrawal syndrome in critically ill patients: protocolized versus nonprotocolized management. J Trauma Acute Care Surg. 2014 Dec. 77 (6):938-43. [Medline].

  11. Schmidt KJ, Doshi MR, Holzhausen JM, Natavio A, Cadiz M, Winegardner JE. A Review of the Treatment of Severe Alcohol Withdrawal. Ann Pharmacother. 2016 Feb 9. [Medline].

  12. Krishel S, SaFranek D, Clark RF. Intravenous vitamins for alcoholics in the emergency department: a review. J Emerg Med. 1998 May-Jun. 16(3):419-24. [Medline].

  13. Schabelman E, Kuo D. Glucose before thiamine for Wernicke encephalopathy: a literature review. J Emerg Med. 2012 Apr. 42 (4):488-94. [Medline].

  14. Sarai M, Tejani AM, Chan AH, Kuo IF, Li J. Magnesium for alcohol withdrawal. Cochrane Database Syst Rev. 2013 Jun 5. 6:CD008358. [Medline].

  15. Weinberg JA, Magnotti LJ, Fischer PE, et al. Comparison of intravenous ethanol versus diazepam for alcohol withdrawal prophylaxis in the trauma ICU: results of a randomized trial. J Trauma. 2008 Jan. 64(1):99-104. [Medline].

  16. Friedmann PD. Clinical practice. Alcohol use in adults. N Engl J Med. 2013 Jan 24. 368(4):365-73. [Medline].

  17. Connor JP, Haber PS, Hall WD. Alcohol use disorders. Lancet. 2016 Mar 5. 387 (10022):988-98. [Medline].

  18. Amato L, Minozzi S, Davoli M. Efficacy and safety of pharmacological interventions for the treatment of the Alcohol Withdrawal Syndrome. Cochrane Database Syst Rev. 2011. (6):CD008537. [Medline].

  19. McCowan C, Marik P. Refractory delirium tremens treated with propofol: a case series. Crit Care Med. 2000 Jun. 28(6):1781-4. [Medline].

  20. Hendey GW, Dery RA, Barnes RL, Snowden B, Mentler P. A prospective, randomized, trial of phenobarbital versus benzodiazepines for acute alcohol withdrawal. Am J Emerg Med. 2011 May. 29(4):382-5. [Medline].

  21. Rosenson J, Clements C, Simon B, Vieaux J, Graffman S, Vahidnia F. Phenobarbital for Acute Alcohol Withdrawal: A Prospective Randomized Double-blind Placebo-controlled Study. J Emerg Med. 2013 Mar. 44(3):592-598.e2. [Medline].

  22. Foster C, Mueller S, Vanderweide L, Kiser T, Fish D, MacLaren R. Addition of dexmedetomidine to the standard of care for severe alcohol withdrawal [abstr]. Critic Care Med. 2012 Dec. 40(12):doi: 10.1097/01.ccm.0000424341.32883.e7.

  23. Linn DD, Loeser KC. Dexmedetomidine for Alcohol Withdrawal Syndrome. Ann Pharmacother. 2015 Dec. 49 (12):1336-42. [Medline].

  24. Minozzi S, Amato L, Vecchi S, Davoli M. Anticonvulsants for alcohol withdrawal. Cochrane Database Syst Rev. 2010. (3):CD005064. [Medline].

  25. Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med. 2004 Jul 12. 164(13):1405-12. [Medline].

  26. Jaeger TM, Lohr RH, Pankratz VS. Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients. Mayo Clin Proc. 2001 Jul. 76(7):695-701. [Medline].

  27. Muzyk AJ, Leung JG, Nelson S, Embury ER, Jones SR. The role of diazepam loading for the treatment of alcohol withdrawal syndrome in hospitalized patients. Am J Addict. 2013 Mar. 22(2):113-8. [Medline].

Previous
Next
 
Average annual deaths from alcohol.
Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). The CIWA-Ar is not copyrighted and may be reproduced freely. This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. The maximum score is 67 (see instrument). Patients scoring less than 10 do not usually need additional medication for withdrawal. From Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 1989;84:1353-1357.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.