Delirium tremens

Definition

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

Alternative Names

DTs; Alcohol withdrawal - delirium tremens

Causes

Delirium tremens can occur when you stop drinking alcohol after a period of heavy drinking, especially if you do not eat enough food.

Delirium tremens may also be caused 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 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 people who have had an alcohol habit or alcoholism for more than 10 years.

Symptoms

Symptoms most often occur within 72 hours after the last drink. However, they may occur up to 7 - 10 days after the last drink.

Symptoms may get worse quickly, and can include:

• Body tremors
• Changes in mental function
  • Agitation, irritability
  • Confusion, disorientation
  • Decreased attention span
  • Deep sleep that lasts for a day or longer
  • Delirium
  • Excitement
  • Fear
  • Hallucinations (seeing or feeling things that are not really there)
  • Increased activity
  • Quick mood changes
  • Restlessness, excitement
  • Sensitivity to light, sound, touch
  • Stupor, sleepiness, fatigue
• Seizures
  • Most common in first 12 - 48 hours after last drink
  • Most common in people with past 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
  • Insomnia (difficulty falling and staying asleep)
  • Irritability or excitability
  • Loss of appetite
  • Nausea
  • Pale skin
  • Palpitations (sensation of feeling the heart beat)
  • Rapid emotional changes
  • Sweating, especially on the palms of the hands or the face
  • Vomiting

Other symptoms that may occur:

• Chest pain
• Fever
• Stomach pain

Exams 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:

• Blood magnesium level
• Blood phosphate level
• Comprehensive metabolic panel
• 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 needed. 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 irregular heartbeat are treated with the following medications:

• Anticonvulsants such as phenobarbital
• Central nervous system depressants such as diazepam or lorazepam
• 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 also help treat seizures, anxiety, and tremors.

Antipsychotic medications such as haloperidol may sometimes be needed for persons with hallucinations. However, these drugs should be avoided if possible because they may contribute to seizures.

Long-term preventive treatment should begin after the patient recovers from immediate symptoms. This may involve a "drying out" period, in which no alcohol is allowed. Total and lifelong avoidance of alcohol (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 needed, treated for other medical problems that can occur 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.

Outlook (Prognosis)

Delirium tremens is serious and may be life threatening. Some symptoms may last for a year or more, including:

• Emotional mood swings
• Feeling tired
• Sleeplessness

Possible Complications

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

When to Contact a Medical Professional

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.

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