Best Case Ever 50 – Delirium Tremens

In anticipation of EM Cases Episode 87 on Alcohol Withdrawal Dr. Sara Gray describes her Best Case Ever of severe alcohol withdrawal and Delirium Tremens from Janus General. Also on this podcast Dr. Anand Swaminathan reacts to Episode 86 Emergency Management of Hyperkalemia and gives us his take on the use of calcium in the setting of digoxin toxicity. Early recognition and treatment of Delirium Tremens - a rapid onset of severe alcohol withdrawal accompanied by delirium and autonomic instability about 3-10 days after the appearance of withdrawal symptoms -  is key to preventing long term morbidity and mortality. This is sometimes easier said than done as some patients will deny alcohol use all together and the differential diagnosis for delirium is lengthy to say the least. It's helpful to know the predictors of Delirium Tremens (listed below) to anticipate and help with early recognition. It is also important to understand that the CIWA score is not a diagnostic test for alcohol withdrawal or delirium tremens. It is a scale to determine severity of withdrawal and guide treatment and should not be used for delirium tremens. Sometimes these patients require the kind of dosages of benzodiazepines that would render most of us comatose, and being comfortable with the use of high dose benzodiazepines as well as second line agents is important in management of these patients. All this and more will be discussed in Episode 87... Published by Anton Helman, October 2016 Predictors of Delirium Tremens * CIWA-Ar score above 15 (especially if SBP >150 or HR>100 ) * Recent withdrawal seizures (seen in 20% of persons with delirium) * History of withdrawal delirium or seizures * Older age * Recent misuse of other depressant agents * Concomitant medical problems including electrolyte abnormalities (e.g., low levels of potassium, magnesium, or both), low platelet counts, and respiratory, cardiac, or gastrointestinal disease   Dr. Gray and Dr. Helman have no conflicts of interest to declare   References Schuckit MA. Recognition and management of withdrawal delirium (delirium tremens). N Engl J Med. 2014;371(22):2109-13. Full PDF