Neobook — clinical reference

ICD-10 code: F10.232

DESCRIPTION

Although the typical delirium occurs 2 - 3 days following cessation of prolonged alcohol intake, reaching a peak at around 5 days, some withdrawal symptoms, such as the typical tremor, may start within 12 hours.

Typical clinical features include:

predominantly visual hallucinations; may have delusions,
disorientation, fluctuating level of consciousness,
agitation,
seizures (tonic-clonic), and
hypertension, tachycardia.

A low-grade fever may be present. Withdrawal tonic-clonic seizures may occur between 24 and 48 hours following cessation of alcohol intake. General medical conditions, e.g. meningitis and other substance use, e.g. sedative-hypnotics should be excluded.

Mortality 1 - 5%.

GENERAL AND SUPPORTIVE MEASURES

Monitor vital signs regularly.
Cardiac monitoring and oximetry should be used when administering large doses of benzodiazepines.
Correct dehydration and abnormalities of electrolytes and nutrition.
Consider parenteral fluids to compensate for severe losses, i.e. in hyperthermia.

MEDICATION TREATMENTAdult management can be applied to adolescents (for young children, management and dosing to be determined in conjunction with a specialist):

Thiamine, IV
- Thiamine must be given prior to glucose to prevent Wernicke-Korsakoff syndrome.
- 500 mg 8 hourly, diluted in 100 ml normal saline infused over 30 minutes for 3 days.
- Followed by 250 mg 8 hourly.
Thiamine, oral.
- 100 mg daily once stable.

Benzodiazepines:

Diazepam, slow IV, 10 mg (not IM due to erratic absorption).
- Repeat dose after 5 - 10 minutes if required.
- If this dose is not sufficient, use 10 mg every 5 - 10 minutes for another 1 - 2 doses.
- If patient is not yet sedated, continue with doses of 20 mg.
- Usual initial dose is 10–20 mg, but up to 60 mg is occasionally required.

Where intravenous access is not possible:

Clonazepam, IM, 1–2 mg as a single dose.
- If no response, repeat dose after 60 minutes.
- Maximum daily dose: 10 mg.

Lorazepam, IM, 1 - 4 mg every 30 - 60 minutes until the patient is sedated.
- Repeat doses hourly to maintain mild sedation.
- Maximum daily dose: 6 mg.

Once patient is sedated, i.e. light somnolence, maintain mild sedation with:

Diazepam, oral, 5 - 20 mg 2 - 6 hourly.

Severe agitation and restlessness:

Haloperidol, IV/IM, 0.5 - 5 mg.
- Repeat after 4 - 8 hours as required to a maximum of 10 mg daily.
- Once patient has responded and is able to take oral medication: Haloperidol, oral, 0.75 - 5 mg 6 - 8 hourly.

Note: Haloperidol, may reduce the seizure threshold.
Consider only for severe agitation and restlessness and give in combination with one of the sedative-hypnotic agents above.

For children with hyperactive delirium:

Medication may be considered to reduce symptoms such as anxiety, agitation, hallucinations and disturbed sleep. Pharmacokinetics in children is different from adults. Before starting pharmacological treatment, the risk of side effects and interactions with other medications and the route of administration have to be considered and weighed against the potential benefits of treatment.
Diazepam, IV.
- 0.2 mg/kg, very slowly over 3 minutes.
- This may be repeated over 24 hours to a maximum of 5 mg for < 5 years and 10 mg for > 5 years.
- The IV solution can be given rectally if the IV route is inaccessible. Maximum dose over 24 hours: 5 mg for < 3 years and 10 mg for > 3 years.

Oral therapy
Oral doses of haloperidol and risperidone are the same for hyperactive paediatric delirium.

Risperidone, oral.
- Weight: < 45 kg
  - Loading dose: 0.02 mg/kg.
  - Maintenance dose: 0.01–0.08 mg/kg/day divided into 2–4 doses.
  - Maximum dose: 4 mg/day divided into 2–4 doses.
- Weight: > 45 kg
  - Loading dose: 0.5–1 mg.
  - Maintenance dose: 0.01–0.08 mg/kg/day divided into 2–4 doses.
  - Maximum dose: 6 mg/day divided into 2–4 doses.
  - Dosages > 6 mg have not been studied.

Haloperidol, oral.
- Weight: < 45 kg
  - Loading dose: 0.02 mg/kg.
  - Maintenance dose: 0.01 - 0.08 mg/kg/day divided into 2 - 4 doses.
  - Maximum dose: 4 mg/day divided into 2 - 4 doses.
- Weight: > 45 kg
  - Loading dose: 0.75 - 1 mg.
  - Maintenance dose: 0.01–0.08 mg/kg/day divided into 2 - 4 doses.
  - Maximum dose: 6 mg/day divided into 2 - 4 doses.
  - Dosages > 6 mg have not been studied.
Extrapyramidal symptoms are seen frequently, particularly if antipsychotics are increased rapidly. Start low and go slow is an important principle. It can take 24 to 48 hours before an adequate response is achieved. Recognizing and treating adverse effects is important.
Treatment consists of reducing the dose of antipsychotic and administration of an anticholinergic medication such as biperiden (50 μg/kg, IV, over 15 minutes).
In adult patients, lengthening of the QTc interval has been reported with the possibility of Torsade’s de Pointes. This has not been reported in children. An ECG is required before starting treatment with haloperidol.
Risperidone has fewer adverse effects than haloperidol and is thus the treatment of choice when symptoms are not extreme and oral administration is possible.
When no benefit is obtained with one medication, a switch to the other should be considered.
A paediatric delirium rating scale should be used at least three times daily to score delirium when medication is started and for as long as the patient receives medication.
It is not known for how long treatment should continue. Experts advise to continue treatment at least until symptoms have disappeared and until risk factors that possibly led to the delirium have lessened. Medication should be weaned gradually, over a few days.

REFERRAL

Refer all children and adolescents with suspected alcohol withdrawal delirium immediately once stabilised.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition

Chapter 14: Child & Adolescent Psychiatry, 14.13 Substance Use Disorder, 14.13.3 Substance Withdrawal, 14.13.3.2 Alcohol Withdrawal Delirium

Drugs mentioned