Management of delirium tremens – first10em youtube gas pedal dance


A 58 year old man is brought into the emergency department by his girlfriend because she thinks he had a seizure at home. He has a long history of alcoholism, and usually drinks about 1 litre of Newfoundland Screech electricity experiments for preschoolers rum every day. However, he had to stop drinking 3 days ago because of a brief stint in jail. He is tremulous, diaphoretic, confused, and complaining of visual hallucinations. His vital signs are electricity and magnetism purcell pdf a temperature of 37.8°C, heart rate 155, blood pressure 166/99, respiratory rate 22, and oxygen saturation 99% on room air…

Walking up to the patient, I always start with a rapid assessment of the ABCs to consider the need to immediate intervention. In the agitated patient, my first priority is to calm the room and the patient down. Verbal de-escalation is valuable electricity bill calculator, but frequently fails in patients with medical or toxicologic agitation. Therefore, it is essential to ensure you have the appropriate people present to ensure that both the patient and staff are safe. ( EMCrit has a good review of the management of the violent agitated patient here .)

The treatment for alcohol withdrawal is a benzodiazepine. I honestly don’t think the benzo you choose matters that much electricity dance moms full episode. I use diazepam because its maximal effect intravenously is seen at about 5 minutes, so it is easily and safely titrated and its long half life provides some degree of auto-taper. My first dose is 10mg, and this dose is repeated once at 5 minutes if response is not adequate. (It won’t be in this patient.) I then double the dose to 20mg and continue with 20mg, 30mg, 30mg, 40mg, then 40mg every 5 minutes as needed mp electricity bill payment.

You have to balance the risks of undertreatment (such as seizure) with the risks of oversedation (aspiration or loss of airway). In mild alcohol withdrawal, titration is usually done by nurses following the CIWA score . However, severe alcohol withdrawal requires rapid titration electricity facts ks2 of very high doses of benzodiazepines that will often make nurses uncomfortable. Therefore, I take charge of the titration. My target is a calm and cooperative, or mildly sedated patient. This would be the equivalent of a Richmond Agitation Sedation Scale of 0 or -1, or a Riker Sedation Analgesia Scale of 3-4. (I don’t have these scales memorized gas konigsforst, so my target really is “calm and cooperative”.)

Once I have started titrating my benzodiazepines, I take some time to consider the wider differential diagnosis. Often, alcohol withdrawal will be obvious. However, in delirium tremens, the patients will have altered mental status, abnormal vital signs, and often a fever. The differential is quite large, including infection, trauma, endocrine and electrolyte abnormalities. A CT of the head is likely on the table, as well as a number of labs. I would also consider gas house pike frederick md empiric antimicrobials to cover meningitis and possibly herpetic encephalitis.

If the patient has not responded after my second or third 40mg dose of diazepam (over 200mg total), I will move on to second line agents. One option electricity generation definition is to add phenobarbital 65-130mg IV q30min. Dexmedetomidine and ketamine have also been discussed as options. However, my plan at this point is to intubate using propofol as an induction agent and start a propofol infusion (as well as my normal post-intubation fentanyl infusion.) The ideal choice of second line agent probably depends on the familiarity you and your electric utility companies in california team have with the various options.

There is evidence (see Gold 2007 below) that you can limit intubation by using a protocol that uses high doses of phenobarbital. There is even an argument to abandon the benzodiazepines altogether, and use phenobarbital as a sole agent ( see a brilliant post by Josh Farkas on PulmCrit here .) However, in my community setting, severe electricity in homes alcohol withdrawal is rare and phenobarbital is almost never used. As always, evidence based medicine is a balance between the literature with what you think is best for your patients in your practice environment. That being said, as more evidence on this topic emerges, I would not be surprised gas prices going up to 5 dollars if I had to update this post to include phenobarbital sometime in the future.

1) Phenobarbital monotherapy is interesting, but I don’t think there is enough evidence for it to be a standard recommendation yet. The benefit static electricity sound effect seen (generally a decrease in intubation rate) has to be balanced with the potential complications of using a medication people are generally much less familiar with than benzodiazapines. For now, I think that benzos should remain the standard except for teams who manage DTs frequently and have expertise in the use of phenobarb. Good evidence could change that position in the future though.

2) I am not aware of cerebral edema being a large component of delirium tremens. On the electricity song youtube other hand, almost all alcoholic patients this sick will be significantly malnourished and are at risk of hypoglycemia. That being said, these all very sick patients and a thorough assessment and guided resuscitation will ultimately take precedence over any empiric management strategy. That being said, while waiting for labs to return, I do not think there is any harm in giving some inert gas definition chemistry glucose containing fluids. (It doesn’t have to be D5W if you are worried about the water load – there are solutions of glucose plus saline as well).