Q: All of the following drugs can be used as a rescue therapy in refractory delirium tremens (DT) except?

A) phenobarbital 
B) Propofol 
C) dexmedetomidine 
D) haloperidol 
E)) higher dose of lorazepam


Answer:  D

Once patient requires more than 10 mg of lorazepam, suspicion for refractory DT should be raised. Lorazepam dose can be further escalated  up to 40 mg in first four hours of treatment (as far as hemodynamics remain stable). All other choices in this question i.e A, B and C are appropriate choices.

Phenobarbital has the advantage of working in synergy with benzodiazepines 1.

Dexmedetomidine is now frequently used as it may help in avoiding mechanical intubation, though evidence-based used is still weak 2.

Propofol is another excellent choice though it surely buys mechanical ventilation 3.

Haloperidol should never be used used or to least with maximum caution as  it lower the seizure, interfere with heat dissipation and cause QT prolongation.


References:

1. Rosenson J, Clements C, Simon B, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med 2013; 44:592. 

2. Tolonen J, Rossinen J, Alho H, Harjola VP. Dexmedetomidine in addition to benzodiazepine-based sedation in patients with alcohol withdrawal delirium. Eur J Emerg Med 2013; 20:425. 

3. McCowan C, Marik P. Refractory delirium tremens treated with propofol: a case series. Crit Care Med 2000; 28:1781.