Delirium Tremens (DTs) Workup

  • Author: Michael James Burns, MD, FACEP, FACP; Chief Editor: Michael R Pinsky, MD, CM, FCCP, FCCM   more...
 
Updated: Jun 29, 2011
 

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.

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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
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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.

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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. Obtain cervical spine radiographs if any question or suspicion of trauma or head injury exists.

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
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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.

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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 College of Emergency Physicians, American College of Physicians, American Society of Tropical Medicine and Hygiene, California Medical Association, Infectious Diseases Society of America, Phi Beta Kappa, Royal Society of Tropical Medicine and Hygiene, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

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.

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.

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, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

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 and American College of Emergency Physicians

Disclosure: Nothing to disclose.

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.

Specialty Editor Board

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.

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

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.

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.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM  Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center

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

Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author William G Gossman, MD, to the development and writing of a source article.

References

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  4. [Guideline] 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. Mar 2007;35(3):724-30. [Medline].

  5. 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. Jan 2008;64(1):99-104. [Medline].

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

  7. 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. May 2011;29(4):382-5. [Medline].

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

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

 
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