PSYCHOBEHAVIORAL DISORDERSTREATMENT
■ ABCs, IV/O 2 /monitor, banana bag (thiamine, folate, multivitamins)
■ Benzodiazepines are the mainstay of treatment.
■ β-Blockers or clonidine may be used to control autonomic hyperactivity.
■ Haldol or other antipsychotics may be used as an adjunct to benzo-
diazepines for delirium, delusions, or hallucinations (but be careful
because it can lower the seizure threshold).
■ Anticonvulsant use is typically not indicated unless the patient has a
known seizure disorder.
■ Admit if pt has >2 seizures in the ED.
DELIRIUMTREMENS
DTs usually occur in patients with a history of heavy, long-term alcohol use.
About 5% of patients who withdraw from alcohol will proceed to DTs, which
usually begin 3–5 days after cessation.
RISKFACTORS
■ History of DTs
■ BAC>300 upon presentation
■ Alcohol withdrawal seizuresupon presentation
■ Comorbid medical illness(cardiovascular, pulmonary, renal disease, infec-
tion, electrolyte abnormalities)
DIFFERENTIAL
Sepsis, meningitis, hypoxia, hypoglycemia, hepatic failure, intracranial bleed
DIAGNOSIS
Symptoms are similar to severe alcohol withdrawal except these patients exhibit
autonomic instability, disorientation, visual or tactile hallucinations, paranoid
ideation, and delirium. Coma and death may result.
TREATMENT
Treatment includes supportive care, aggressive use of benzodiazepines (may
need to start a continuous infusion). All patients with DTs will need to be
admitted to the ICU.
WERNICKEENCEPHALOPATHY
Occurs in heavy drinkers and severely malnourished patients, secondary to
thiamine (vitamin B 1 ) deficiency. Consideration for Wernicke encephalopathy
should be given to patients with any evidence of long-term alcohol abuse or
malnutrition or who present with altered mental status.
In addition, hypotension or hypothermia (due to autonomic and temperature
dysregulation) may occur.
TREATMENT
Thiamine!(The question about whether this should be given before glucose
is controversial).
Diagnosis of
Wernicke
encephalopathy—
Wernicke
Nystagmus and
opthalmoplegia
Incoordination, ataxia
Confusion