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Delirium tremens — ABIM Board MCQ

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HardPsychiatry relevant to IMDelirium tremensABIM Board

A 50-year-old man with severe alcohol withdrawal remains markedly agitated despite escalating benzodiazepines in an ICU. He is not intubated, continuous cardiorespiratory monitoring is available, and the team is concerned about progressive benzodiazepine toxicity. Which adjunct is reasonable under an experienced protocol?

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Correct answer: D — Add phenobarbital with close respiratory and hemodynamic monitoring

The best answer is “Add phenobarbital with close respiratory and hemodynamic monitoring”. Phenobarbital can be used as an adjunct for resistant severe withdrawal by clinicians experienced with its narrow therapeutic window, ideally in a highly monitored setting because respiratory depression and oversedation can be synergistic with benzodiazepines. Antipsychotics and beta blockers do not treat the underlying withdrawal physiology, and flumazenil can provoke seizures.

Reference: ASAM Clinical Practice Guideline on Alcohol Withdrawal Management: https://downloads.asam.org/sitefinity-production-blobs/docs/default-source/quality-science/the_asam_clinical_practice_guideline_on_alcohol-1.pdf