Delirium Tremensawarenessxyzxyzxyzz.pptx

Psychiatry

1. ALCOHOL WITHDRAWAL: DELIRIUM MANAGEMENT Presenter : Dr. Shivansh Agarwal Guide : Dr. Manjeet Santre

2. S CHEME OF P RESENTATION Introduction Pathophysiology of Alcohol Dependence Alcohol Withdrawal Delirium Tremens Summary References

3. INTRODUCTION Alcohol is one of the most commonly used chemical substances for intoxication by humans in history. About half of the global population aged more than 15 years uses alcohol. (WHO Global Status Report on Alcohol and Health, 2018) Around half (43%) of alcohol users consume ‘more than four drinks on a single occasion’ (indicating ‘ Heavy Episodic drinking ’). When patients with Alcohol Use Disorder (AUD) abruptly stop or reduce their alcohol consumption, up to 50% experience withdrawal symptoms. Approximately 10% of them develop withdrawal seizures , and 5% develop Delirium Tremens . Delirium Tremens is a Medical emergency with mortality rate of 20- 50% of patients if not treated, and at times 5-10% mortality even with treatment.

4. ALCOHOL DEPENDENCE Neurotransmitters mediating effect of alcohol on brain are: GABA Glutamate Dopamine Serotonin Pathophysiology : Alcohol enhances the effect of GABA on GABA-A neuroreceptors, resulting in decreased overall brain excitability. Chronic exposure : compensatory decreased response to GABA, evidenced by increasing tolerance of the effects of alcohol Alcohol further decreases electrical activity by inhibiting the major excitatory neurotransmitter, Glutamate , particularly at N-methyl- d-aspartate ( NMDA ) receptor. Chronic exposure: compensatory up-regulation of NMDA receptors.

5. Pathophysiology : ALCOHOL DEPENDENCE IMPORTANT NOTES ⦁ With chronic use Sensitivity is ↓ for GABA & ↑ for Glutamate .

6. ALCOHOL WITHDRAWAL Withdrawal: A group of symptoms and signs which occur on cessation or reduction of use of a psychoactive substance, that has been taken repeatedly, usually for a prolonged period and/ or in high doses. Mild Alcohol Withdrawal: Onset : 3-12 hours; Peak : 24-48 hours; Duration : upto 14 days. Signs & symptoms: Agitation/Anxiety/Irritability Tremors of hands, tongue, eyelids Sweating, Tachycardia , Systolic HTN Insomnia, Fever Nausea/Vomiting/Diarrhoea Clear sensorium (intact orientation). Manifestations :

7. ALCOHOL WITHDRAWAL Moderate to Severe Alcohol Withdrawal: Alcoholic hallucinosis: Onset : 12-24 hours visual, tactile, or auditory hallucinations Alcohol withdrawal seizure: Onset : 24‐48 hours One or two generalized tonic‐clonic seizure Multiple seizures (upto 6) can occur High risk of progression to Delirium Tremens Manifestations :

8. Timeline : IMPORTANT NOTES ⦁ With chronic use Sensitivity is ↓ for GABA & ↑ for Glutamate . ⦁ 6-12 hr: Mild withdrawal ⦁ 12-24 hr: Alcoholic hallucinosis ⦁ 24-48 hr: Withdrawal seizures ⦁ 48-72 hr: Delirium Tremens ALCOHOL WITHDRAWAL Time W ithdrawal S ymptoms 6 to 12 hours Insomnia, tremulousness , mild anxiety, gastrointestinal upset, headache, diaphoresis, palpitations, anorexia 12 to 24 hours Alcoholic hallucinosis : visual, auditory, or tactile hallucinations 24 to 48 hours Withdrawal seizures : generalized tonic-clonic seizures 48 to 72 hours Alcohol withdrawal delirium ( D elirium T remen s ) : hallucinations ( predominantly visual), disorientation, tachycardia, hypertension, low-grade fever, agitation, diaphoresis

9. ALCOHOL WITHDRAWAL Delirium : A state of confusion and disorientation, often accompanied by hallucinations and other cognitive changes. Delirium tremens is the m ost severe neurological complication of alcohol withdrawal with high mortality rate, characterised by: Usual alcohol withdrawal symptoms Clouding of consciousness Hallucinations Tremors Autonomic dysfunctions Medical emergency, likely to develop 48-72 hours after the last drink. Delirium Tremens :

10. ALCOHOL WITHDRAWAL Risk factors : Previous history of withdrawal seizures or delirium tremens Electrolyte Imbalance: Hypokalemia , Hypomagnesemia Dehydration Thiamine deficiency Medical Comorbidities It may also be triggered by infections and head injuries. Delirium Tremens :

11. ALCOHOL WITHDRAWAL Management: Immediate hospitalization: best managed in ICU setting. Regular monitoring of vitals Chlordiazepoxide or Diazepam or Lorazepam : given intravenously repeated till the symptoms clear (or patient is lightly sedated) When liver function tests are normal, diazepam is a better option. Periodic monitoring: Regular vitals and lab parameters Delirium Tremens :

12. ALCOHOL WITHDRAWAL Management: Total dose given on the first day should be the standing dosage given on the second day It should be tapered gradually over 7-10 days . The following general measures should be looked after: maintaining water and electrolyte balance correcting metabolic disturbances nutritional supplement: IV Thiamine The British National Formulary recommends 200-300 mg of thiamine daily for treatment of severe deficiency . Safeguard against injury as patient is frequently confused, disoriented and agitated Delirium Tremens :

13. ALCOHOL WITHDRAWAL Management: Nationa Institute for Health and Care Excellence Guidelines: Recommends Lorazepam . Cautious use of Haloperidol to manage behavioural disturbance Olanzapine : for behavioural disturbances refractory to benzodiazepines New South Wales Guidelines: Recommends Diazepam . Olanzapine: for behavioural disturbances refractory to benzodiazepines Delirium Tremens :

14. ALCOHOL WITHDRAWAL Management: The following points unite these approaches: Doses of benzodiazepines given close together in a loading fashion with a maximum of an hour apart High doses are permitted Antipsychotics, used only after large doses of benzodiazepines have failed.

15. SUMMARY Delirium Tremens : IMPORTANT NOTES ⦁ With chronic use Sensitivity is ↓ for GABA & ↑ for Glutamate . ⦁ 6-12 hr: Mild withdrawal ⦁ 12-24 hr: Alcoholic hallucinosis ⦁ 24-48 hr: Withdrawal seizures ⦁ 48-72 hr: Delirium Tremens ⦁ Past history ⦁ Hypokalemia ⦁ Dehydration ⦁ Thiamine- -deficiency ⦁ Comorbidities ⦁ Management: ⦁ High dose benzodiazepines ⦁ Adequate hydration ⦁ Regular monitoring ⦁ Electrolyte balance ⦁ Thiamine Supplementation R/F C/F ⦁ Disorientation ⦁ Haluccinations ⦁ Autonomic Dys. ⦁ Tremors Alcohol is a commonly used substance that causes withdrawal symptoms when abruptly discontinued or consumed in smaller amounts. Alcohol Withdrawal can get complicated in some cases and progress to: Alcohol Withdrawal Hallucinosis Alcohol Withdrawal Seizures Delirium Tremens Delirium Tremens is a medical emergency and appropriate management requires joint work between psychiatric, medical and nursing teams. W ith proper management, such situations can be avoided, and mortality can be greatly reduced.

16. REFERENCES Grover, S., & Ghosh, A. (2018). Delirium Tremens: Assessment and Management. Journal of Clinical and Experimental Hepatology, 8(4), 460. Kattimani, S., & Bharadwaj, B. (2013). Clinical management of alcohol withdrawal: A systematic review. Industrial Psychiatry Journal, 22(2), 100. Littleton, J. (1998). Neurochemical Mechanisms Underlying Alcohol Withdrawal. Alcohol Health and Research World, 22(1), 13. Mirijello, A., D’Angelo, C., Ferrulli, A., Vassallo, G., Antonelli, M., Caputo, F., Leggio, L., Gasbarrini, A., & Addolorato, G. (2015). IDENTIFICATION AND MANAGEMENT OF ALCOHOL WITHDRAWAL SYNDROME. Drugs, 75(4), 353. The Maudsley: Prescribing Guidelines in Psychiatry 14th Edition Clinical Practice Guidelines for assessment and management of substance use disorders.

17. Thank You!