Delirium tremens

Definition

Delirium tremens is a disorder involving sudden and severe mental changes (psychosis) or neurologic changes (including seizures) caused by abruptly stopping the use of alcohol. Rapid pulse rate, elevated blood pressure, and temperature elevation also may be present.

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 use of alcohol. It is most common in people who have a history of experiencing alcohol withdrawal when alcohol is stopped, especially in those who drink the equivalent of 7 - 8 pints of beer (or 1 pint of "hard" alcohol) per day for several months, and in those with a history of habitual alcohol use or alcoholism that has existed for more than 10 years.

Symptoms occur because of the toxic effects of alcohol on the brain and nervous system. They may be severe and progress rapidly.

Symptoms

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

• Fever
• Stomach pain
• Chest pain

Signs and tests

Delirium tremens is a medical emergency. The health care provider should be consulted promptly.

An examination of the neuromuscular system may show an increased startle reflex, rapid rhythmic muscle tremor, or other changes indicating alcohol withdrawal. Evidence of increased autonomic function -- such as profuse sweating -- may be present.

There may be symptoms of dehydration or malnutrition, and signs indicating electrolyte disturbances. An eye inspection may show abnormalities of eye muscle movement -- such as lid lag. The heart rate may be rapid, and there may be an irregular heart beat. The blood pressure may be normal, elevated, or low.

A serum toxicology screen is usually positive for alcohol. Serum chemistry (chem-20) may show electrolyte disturbances, especially decreased levels of potassium and magnesium. An ECG (electrocardiogram) may show arrhythmias. An EEG (electroencephalogram) may be performed to rule out other causes of seizures.

Treatment

This is an emergency condition. The goals of treatment are saving the patient's life, treating the immediate symptoms, and preventing complications. Long-term preventive treatment may begin after initial treatment of the acute condition. Hospitalization is required. Vital signs (temperature, pulse, rate of breathing, blood pressure), and fluid and electrolyte status are monitored, and abnormalities are treated as appropriate.

Seizures and cardiovascular conditions, such as heart arrhythmias, are treated as appropriate. This may include lifesaving or life-support measures, anticonvulsant medications such as phenytoin, or other medications. Clonidine may reduce cardiovascular symptoms, and helps reduce anxiety. Central nervous system depressants and sedatives may be required, often in large doses, to reduce symptoms.

Treatment may require maintenance of a sedated state for a week or more until withdrawal is complete. Benzodiazepine medications such as diazepam are often useful to provide sedation. Diazepam is also useful to treat seizures as well as anxiety and tremors.

Hallucinations are treated similarly to any acute psychotic episode, with hospitalization as needed. Cautious use of antipsychotic medications, such as haloperidol, may be necessary in some cases.

A "drying out" period may be appropriate. No alcohol is allowed during this time. Treatment for alcohol use or alcoholism is recommended. This may include psychologic interventions, social supports such as AA (Alcoholics Anonymous), behavior modification, or other interventions.

Testing and treatment for other medical problems associated with use of alcohol is necessary. This may include disorders such as alcoholic liver disease, blood clotting disorders, alcoholic neuropathy, heart disorders (such as alcoholic cardiomyopathy), chronic brain syndromes (such as 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

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

Calling your health care provider

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

Prevention

Avoid or minimize the use of alcohol. Treat known alcoholism appropriately. Obtain prompt medical treatment for symptoms of alcohol withdrawal. Also, look into alcohol detoxification or "detox" centers in your area, as well as alcohol rehabilitation centers or "rehab" facilities.

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