Delirium Tremens and Alcohol Withdrawal Syndrome

 

Delirium Tremens

Alcohol Withdrawal Syndrome: an acute toxic state that occurs as a result of sudden alcohol cessation following prolonged alcohol intake.

Symptoms severity depends on the duration and alcohol quantity ingested.

Delirium Tremens may be precipitated by acute injury or infection such as pneumonia, pancreatitis or hepatitis.

Alcohol Withdrawal Symptoms:

  1. anxiety
  2. uncontrollable fear
  3. tremor
  4. irritability
  5. agitation
  6. insomnia
  7. incontinence
  8. hallucinations (visual, tactile, olfactory, auditory)
  9. Extremely talkative

Autonomic overactivity occurs resulting in:

  1. tachycardia
  2. pupil dilation
  3. profuse perspiration
  4. elevated vital signs
  5. condition is life threatening and carries a high mortality rate

 

Management

  • Goal: to give adequate sedation and support to facilitate patient rest and recovery while preventing injury and peripheral vascular collapse
  • Physical exam is performed to identify preexisting or contributing illness or injury
  • Drug history is obtained to elicit information and facilitate supplementation of sedative requirements
  • Baseline blood pressure obtained as subsequent treatment may depend on blood pressure changes
  • Typically patient is sedated as directed with sufficient dosages of benzodiazapines to establish and maintain sedation
  • Sedation acts to reduce agitation, prevent exhaustion, prevent seizures and promote adequate rest.
  • Sedation guideline: Patient should be calm, able to respond and able to maintain own airway safely

 

Pharmacologic Management:

  1. Chlordiazepoxide
  2. Lorazepam
  3. Clondine

Management of severe symptoms

  1. Haloperidol
  2. Droperidol
  3. Phenytonin (Dilantin) used to prevent repeated withdrawal seizures

 

Dosage adjustment is based on patient’s symptoms of agitation, anxiety level and blood pressure response.

Optimum Environment:

  1. calm nonstressful environment
  2. patient under close supervision
  3. closet or bathroom doors are closed to eliminate shadows
  4. Room lighting remains to minimize potential for illusions of hallucinations
  5. Homicidal or suicidal thoughts may result from hallucinations
  6. Frequent checks and reassurance offered to calm patient
  7. Patient is frequently reoriented to maintain contact with reality

 

The use of restraints:

  • used as prescribed if necessary
  • used when patient is violent or aggressive
  • used when other alternatives have been unsuccessful
  • use of least restrictive device that will effectively prevent patient from injuring self or others
  • caution taken to ensure restraints are applied properly and not impairing circulation or impeding respirations
  • restraints checked and reassessed hourly or as per facility protocol

 

Ongoing Physical observation of the following:

  • skin integrity
  • circulatory status
  • respiratory status
  • patient response documented

 

Fluid losses:

  • result from gastrointestinal losses such as vomiting, profuse perspiration and respiration (hyperventilation)
  • Patient assessed for dehydration as a result of alcohol effect on decreasing antidiuretic hormone
  • oral or IV fluid restoration and electrolyte balancing used as needed
  • Temperature, pulse, respiration and blood pressure are recorded as frequently as q30min for severe delirium tremens in anticipation of peripheral circulatory collapse or hyperthermia

 

Frequent Complications

  • pneumonia
  • trauma
  • hepatic failure
  • hypoglycemia
  • cardiovascular problems
  • Hypoglycemia may accompany withdrawal due to alcohol depleting hepatic glycogen stores
  • Gluconeogenesis may be impaired due to malnourishment
  • Juice and Osmotically balanced drinks may be used to hydrate, replenish sugars and restore electrolyte balance
  • Vitamin supplements are administered to counteract vitamin deficiency
  • Patients referred to alcohol treatment center following delirium tremens resolution for rehabilitation and follow-up.

Day et al. Textbook of Medical Surgical Nursing. 1st Can. ed.Delirium Tremens. p. 2182 and 2186.  Lippincott Williams and Wilkins.

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