›ACEP Level B recommendation
›Fixed-schedule dosing acceptable when monitoring limitations exist
›Diazepam 10 mg q6h x4 doses, then 5 mg q6h x8 doses
›Add symptom-triggered doses on top of fixed schedule if CIWA-Ar >= 8
Benzodiazepine-resistant DT
›Phenobarbital — adjunct or monotherapy
›Dosing as adjunct
›130–260 mg IV every 15–30 minutes
›Maximum cumulative dose 20 mg/kg
›Mechanism
›Direct GABA-A receptor activation — bypasses benzodiazepine binding site
›Effective when benzodiazepine receptor is saturated
›Cautions
›Respiratory depression risk — especially combined with benzodiazepines
›Requires intubation preparation when using high doses
›Propofol — for intubated patients
›Dosing
›Infusion 5–80 mcg/kg/min, titrate to RASS -2 to 0
›Bolus 0.5–1 mg/kg for acute agitation
›Indications
›Benzodiazepine-resistant DT requiring intubation
›Status epilepticus refractory to benzodiazepines
›Cautions
›Propofol infusion syndrome at doses > 80 mcg/kg/min > 48 hours
›Hypotension — monitor MAP
›Dexmedetomidine — ICU adjunct
›Dosing
›Loading dose 1 mcg/kg over 10 minutes (omit if hemodynamically unstable)
›Maintenance 0.2–1.5 mcg/kg/hr, titrate to comfort
›Role
›May reduce benzodiazepine requirements
›May reduce intubation rate when used as adjunct
›Limitations
›Does not address underlying GABA pathophysiology
›Not adequate as monotherapy for DT
›Midazolam continuous infusion — ICU
›Dosing
›0.02–0.1 mg/kg/hr continuous infusion
›Titrate to RASS -1 to +1
›Advantage — short half-life allows rapid titration
›Disadvantage — accumulation in prolonged infusion or hepatic impairment
Adjunctive pharmacotherapy
›Antipsychotics — adjunct only for persistent hallucinations
›Haloperidol
›2–5 mg IV or IM — for severe agitation as adjunct
›Check QTc before use — avoid if QTc > 500 ms
›Quetiapine 25–50 mg orally if delirium persists > 72 hours
›Risperidone 0.5–2 mg as alternative
›NEVER as monotherapy for DT — lowers seizure threshold
›QTc monitoring mandatory — 63% of DT patients have prolonged QTc
›Beta-blockers — adjunct to reduce autonomic symptoms
›Atenolol or propranolol — adjunct only
›Reduces heart rate and blood pressure but does not prevent seizures
›Not monotherapy — NEVER replace benzodiazepines
›Contraindicated as primary therapy for DT
›Clonidine — alpha-2 agonist
›0.1–0.3 mg orally every 8 hours
›Adjunct for autonomic symptoms — hypertension, tachycardia
›Not adequate as monotherapy for seizure prevention
›Avoid QT-prolonging agents when QTc > 500 ms
›Ondansetron, haloperidol, droperidol — caution in prolonged QTc
Nutritional and electrolyte replacement
›Thiamine replacement
›Standard: 100 mg IV daily for 3–5 days
›Suspected or confirmed Wernicke encephalopathy: 200–500 mg IV q8h
›Administer before or with glucose — never glucose first
›Thiamine 100 mg PO daily on discharge
›Class I recommendation — ASAM Clinical Practice Guideline 2020
›Folate
›1 mg IV daily for critically ill patients
›400–1000 mcg daily dosing range
›Continue as 1 mg PO daily after ICU
›Multivitamin supplementation
›IV multivitamin once daily during acute admission
›Includes B-complex vitamins — niacin, pyridoxine, riboflavin
›Potassium repletion
›Target K+ > 3.5 mmol/l
›IV repletion if < 3.0 mmol/l or unable to take orally
›40 mEq per 1 L bag normal saline over 4 hours
›Magnesium repletion
›Target Mg > 0.85 mmol/l
›IV magnesium sulfate 2–4 g over 2–4 hours if hypomagnesaemia
›Lowers seizure threshold — treat aggressively in DT
›IV fluid strategy
›Dextrose-containing fluids — D5NS or D5 1/2NS
›Correct dehydration from diaphoresis, vomiting, poor intake
›Caution in hyponatraemia — avoid rapid sodium correction
›NPO initially — aspiration risk from altered mental status
Supportive and non-pharmacologic measures
›Environmental measures
›Quiet, well-lit room — reduces perceptual disturbances
›Frequent reorientation by nursing staff
›1:1 nursing observation for agitated patients
›Restraints only when necessary for patient safety
›Soft restraints preferred over chemical restraints where possible
›Seizure management
›Acute seizure — benzodiazepines are treatment and prevention
›Lorazepam 4 mg IV for active seizure
›Phenytoin NOT effective for withdrawal seizures — avoid as sole agent
›Status epilepticus — escalate to propofol or phenobarbital
›Neurology consult
›Aspiration precautions
›Head of bed 30–45 degrees
›Oral suctioning available
›Aspiration pneumonia surveillance — fever, new infiltrate