• Withdrawal delirium (delirium tremens) can mimic many other critical illnesses we see including but not limited to sepsis, toxidromes, excited delirium, and hyperthermia, making it a life-threatening disease that is often underrecognized.
•  Even with delirium tremens is recognized, treatment is often underdosed leading to complications including seizures, worsening of comorbidities, and death.
•  Alcohol withdrawal exhibits symptoms such as insomnia, anxiety, tachycardia, tachypnea, fevers, hypertension and tremors.
• The Clinical Institute Withdrawal Assessment of Alcohol scale (CIWA-Ar) is helpful in determining severity of withdrawal. Scores higher than 15 indicate severe symptoms that require close monitoring in an ICU. Here is the link to MDCalc
  
• Treatment regimens include very high doses of benzodiazepines! Here are possible regimens to consider, but are not the only options. Refer to your hospital’s protocol if you have one:
• Diazepam
•  Regimen 1
• 10-20mg IV or PO every 1-4 hours PRN
•  Regimen 2
• 5mg IV, repeat 10 min later if needed
• 10mg IV 10 min later if needed
• Continue giving 5-20mg as needed therafter
•  Lorazepam
• Regimen 1
• 8mg IV or PO every 15 min PRN. Can give up to 3 doses before starting a drip at 10-30mg/hr
•  Regimen 2
• 1-4mg IV every 15 min PRN
• 1-40mg IM every 30-60min PRN
• Continue dosing every hour as needed to maintain somnolence
• Special considerations: Do not forget to give thiamine prior to glucose so as to not precipitate Wernicke’s encephalopathy or thiamine-related cardiomyopathies!

References

• Schuckit MA. Recognition and management of withdrawal delirium (delirium tremens). N Engl J Med. 2014;371(22):2109-13.