CCS Case: Alcohol Withdrawal — Delirium Tremens

Case: Alcohol Withdrawal — Delirium Tremens

Clinical Setup

• Presentation: 48-year-old male with chronic heavy alcohol use, last drink 3 days ago, now agitated, diaphoretic, tremulous, visual hallucinations, temperature 38.4°C, HR 128, BP 158/96.
• Location: Emergency Department.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring, BP q15min.
   • IV access, Normal saline 0.9% IV @ 100 mL/hr.
   • Seizure precautions, fall precautions, quiet low-stimulation room.
2. Focused Exam (Minute 1–2):
   • Neuro exam (tremor, orientation, hallucinations), CIWA-Ar scoring, abdominal exam (hepatomegaly), skin exam (diaphoresis, jaundice).
3. Diagnostics (Minute 2–5):
   • CBC, BMP (hypokalemia, hypomagnesemia), Magnesium, Phosphate, LFTs, PT/INR.
   • Fingerstick glucose, serum ethanol level, urine drug screen.
   • ECG 12-lead (tachycardia, QTc before antipsychotics if considered).
4. Therapeutics (Minute 5–15):
   • Thiamine 100 mg IV/PO BEFORE glucose (prevent Wernicke encephalopathy), then correct glucose.
   • Replete Magnesium and Potassium IV as needed.
   • Benzodiazepines per CIWA protocol: Lorazepam IV or Diazepam IV (symptom-triggered dosing; scheduled if severe).
   • If refractory agitation despite benzodiazepines: consider Phenobarbital or Dexmedetomidine adjunct per protocol.
   • Advance clock in 30–60 min increments; repeat CIWA scores and vitals.
5. Disposition (Minute 15–20):
   • Admit to ICU if DTs, seizures, autonomic instability, or high CIWA scores.
   • Monitor for withdrawal seizures in first 48 hours.
6. Final 2 Minutes:
   • Counsel on alcohol cessation, rehabilitation programs, Alcoholics Anonymous, relapse prevention.
   • Schedule addiction medicine and primary care follow-up; offer Naltrexone/Acamprosate discussion at follow-up.