Delirium tremens

Definition

Delirium tremens is a severe form of alcohol withdrawal that involves sudden and severe mental or neurological changes.

Alternative Names

DT's; Alcohol withdrawal - delirium tremens

Causes, incidence, and risk factors

Delirium tremens can occur after a period of heavy alcohol drinking, especially when the person does not eat enough food.

It may also be triggered by head injury, infection, or illness in people with a history of heavy alcohol use.

It is most common in people who have a history of alcohol withdrawal. It is especially common in those who drink the equivalent of 4 - 5 pints of wine or 7 - 8 pints of beer (or 1 pint of "hard" alcohol) every day for several months. Delirium tremens also commonly affects those who have had a history of habitual alcohol use or alcoholism for more than 10 years.

Symptoms

Symptoms most commonly occur within 72 hours after the last drink, but may occur up to 7 - 10 days after the last drink. Symptoms may get worse rapidly, and can include:

• Body tremors
• Mental status changes
  • Agitation, irritability
  • Confusion, disorientation
  • Decreased attention span
  • Decreased mental status
    • Deep sleep that persists for a day or longer
    • Stupor, sleepiness, lethargy
    • Usually occurs after acute symptoms
  • Delirium (severe, acute loss of mental functions)
  • Excitement
  • Fear
  • Hallucinations (such as seeing or feeling things that are not present are most common)
  • Highly sensitive to light, sound, touch
  • Increased activity
  • Mood changes rapidly
  • Restlessness, excitement
• Seizures
  • Most common in first 24 - 48 hours after last drink
  • Most common in people with previous complications from alcohol withdrawal
  • Usually generalized tonic-clonic seizures
• Symptoms of alcohol withdrawal
  • Anxiety
  • Depression
  • Difficulty thinking clearly
  • Fatigue
  • Feeling jumpy or nervous
  • Feeling shaky
  • Headache, general, pulsating
  • Insomnia (difficulty falling and staying asleep)
  • Irritability or easily excited
  • Loss of appetite
  • Nausea
  • Pale skin
  • Palpitations (sensation of feeling the heart beat)
  • Rapid emotional changes
  • Sweating, especially the palms of the hands or the face
  • Vomiting

Additional symptoms that may occur:

• Chest pain
• Fever
• Stomach pain

Signs and tests

Delirium tremens is a medical emergency.

The health care provider will perform a physical exam. Signs may include:

• Heavy sweating
• Increased startle reflex
• Irregular heartbeat
• Problems with eye muscle movement
• Rapid heart rate
• Rapid muscle tremors

The following tests may be done:

• Chem-20
• Electrocardiogram (ECG)
• Electroencephalogram (EEG)
• Toxicology screen

Treatment

The goals of treatment are to:

• Save the person's life
• Relieve symptoms
• Prevent complications

A hospital stay is required. The health care team will regularly check:

• Blood chemistry results, such as electrolyte levels
• Body fluid levels
• Vital signs (temperature, pulse, rate of breathing, blood pressure)

Symptoms such as seizures and heart arrhythmias are treated with the following medications:

• Anticonvulsants such as phenytoin or phenobarbital
• Central nervous system depressants such as diazepam
• Clonidine to reduce cardiovascular symptoms and reduce anxiety
• Sedatives

The patient may need to be put into a sedated state for a week or more until withdrawal is complete. Benzodiazepine medications such as diazepam or lorazepam are often used. These drugs also help treat seizures, anxiety, and tremors.

Antipsychotic medications such as haloperidol may sometimes be necessary for persons with hallucinations.

Long-term preventive treatment should begin after the patient recovers from acute symptoms. This may involve a "drying out" period, in which no alcohol is allowed. Total and lifelong abstinence is recommended for most people who go through withdrawal. The person should receive treatment for alcohol use or alcoholism, including:

• Counseling
• Support groups (such as Alcoholics Anonymous)

The patient should be tested, and if necessary, treated for other medical problems associated with alcohol use. Such problems may include:

• Alcoholic cardiomyopathy
• Alcoholic liver disease
• Alcoholic neuropathy
• Blood clotting disorders
• Wernicke-Korsakoff syndrome

Support Groups

For additional resources, see alcoholism support group.

Expectations (prognosis)

Delirium tremens is serious and may be life threatening. Symptoms such as sleeplessness, feeling tired, and emotional instability may persist for a year or more.

Complications

• Heart arrhythmias, may be life threatening
• Injury from falls during seizures
• Injury to self or others caused by mental state (confusion/delirium)
• Seizures

Calling your health care provider

Go to the emergency room or call the local emergency number (such as 911) if you have symptoms. Delirium tremens is an emergency condition.

Prevention

Avoid or reduce the use of alcohol. Get prompt medical treatment for symptoms of alcohol withdrawal.

For more information, see: Alcoholism

References

O’Connor PG. Alcohol abuse and dependence. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 31.