Alcohol withdrawal delirium on a general ward

Diagnosis: alcohol withdrawal delirium (delirium tremens), severe (CIWA-Ar 21), at 36 hours after the last drink - the classic window for withdrawal seizures and delirium.

Risks that determine the first 10 minutes

• Hypoglycaemia, masked by intoxication and liver disease.
• Wernicke encephalopathy - the combination of poor nutrition and alcohol demands thiamine before any glucose load.
• Seizures and arrhythmia from hypomagnesaemia and hypokalaemia.
• Aspiration and falls, particularly with a platelet count of 62 × 10⁹/L and a recent fall.
• Autonomic instability: pulse 118 and temperature 38 °C can precede collapse.

Actions

1. Airway, breathing, circulation; oxygen; continuous observation; move him near the nurses' station.
2. Check capillary blood glucose; give thiamine 200–500 mg intravenously (or intramuscularly) before or with glucose.
3. IV access; send electrolytes including magnesium, calcium, phosphate, liver function, coagulation, full blood count.
4. Give a benzodiazepine (lorazepam preferred - see next answer), start fluids and correct magnesium and potassium.
5. Record vitals and CIWA-Ar hourly until the score falls below 8.

• Diazepam 20 mg 6-hourly - the wrong benzodiazepine here. In decompensated liver disease diazepam has a prolonged half-life with active metabolites that accumulate and deepen sedation and encephalopathy. Use lorazepam, which undergoes glucuronidation and is relatively spared. Preferred approach is symptom-triggered dosing against CIWA-Ar (e.g., lorazepam 2–4 mg IV when the score is above 8), rather than fixed 6-hourly oral doses, because oral absorption and intake are unreliable in delirium.
• Haloperidol 5 mg IM for agitation - antipsychotics are not a substitute for benzodiazepines; they lower the seizure threshold, prolong QT and impair temperature regulation. If used at all, only as a low-dose adjunct after adequate benzodiazepine.
• Physical restraint - increases agitation, rhabdomyolysis, aspiration and venous thrombosis, and is hazardous with thrombocytopenia. Use trained staff, continuous observation, a low bed, soft lighting and orientation instead.
• Nil by mouth - unnecessary if swallowing is intact; it worsens hypoglycaemia and prevents oral thiamine and benzodiazepines. Give oral thiamine, folate and food as soon as safe.
• Keep the bedside free of the relative's diazepam strip and control all medicines.

Monitoring

• Pulse, BP, temperature, respiratory rate, SpO2 and CIWA-Ar every 1–2 hours until the score is below 8 for 24 hours; then 4-hourly.
• Neurological observation and blood glucose every 4 hours initially, more often if he becomes drowsy.
• Strict fluid balance, daily weight, and electrolytes including magnesium, potassium and phosphate.
• Watch specifically for a generalised seizure, aspiration, upper gastrointestinal bleed and arrhythmia; escalate for pulse above 120/min, temperature above 38.5 °C, systolic BP above 180 mmHg, or a seizure.

Three safety interventions

1. Continuous one-to-one observation by a staff member or trained attendant, with the bed at its lowest and side rails padded - not limb restraints.
2. A quiet, well-lit, orienting environment with a clock, calendar and a familiar person present; move him adjacent to the nurses' station because there is no delirium room.
3. Medication control and falls precautions: all medicines held by nursing staff, IV access maintained, no sharps at the bedside, and a documented delirium/falls care plan.

Explain the plan to the family, and document the resident's plan, your objections and the outcome.