Alcohol withdrawal - delirium tremens

Definition

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

Alternative Names

Causes

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 alcohol withdrawal, especially in those who drink the equivalent of 7 - 8 pints of beer (or 1 pint of "hard" alcohol) every day for several months. Delirium tremens also commonly affects 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 get worse very quickly. This is a life-threatening condition that requires immediate medical attention.

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

Exams and Tests

Delirium tremens is a medical emergency.

The health care provider will perform a physical exam. There may be an increased startle reflex, rapid muscle tremors, heavy sweating, and other signs of alcohol withdrawal.

An eye exam may show problems with eye muscle movement. The heart rate may be rapid, and there may be an irregular heart beat.

The following tests may be done:

• Toxicology screen
• Chem-20 (may show decreased levels of potassium and magnesium)
• Electrocardiogram (ECG)
• Electroencephalogram (EEG)

Treatment

The goals of treatment are to save the person's life, relieve symptoms, and prevent complications.

A hospital stay is required. The health care team will regularly check vital signs (temperature, pulse, rate of breathing, blood pressure) and fluid and electrolyte levels.

Symptoms, including seizures and heart arrhythmias, are treated as appropriate. This may include the following medicines:

• Anticonvulsants such as phenytoin
• Clonidine to reduce cardiovascular symptoms and reduce anxiety
• Central nervous system depressants
• 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 are often used. This drug also helps treat seizures, anxiety, and tremors.

In persons with hallucinations, cautious use of antipsychotic medications such as haloperidol may be necessary in some cases.

Long-term preventive treatment may begin after the patient recovers from acute symptoms. This may involve a "drying out" period, in which no alcohol is allowed. The person should receive treatment for alcohol use or alcoholism, including counseling, support groups (such as Alcoholics Anonymous), and other behavior modifications.

The patient should be tested, and if necessary, treated for other medical problems associated with alcohol use. Such problems may include alcoholic liver disease, blood clotting disorders, alcoholic neuropathy, alcoholic cardiomyopathy, and Wernicke-Korsakoff syndrome.

Support Groups

For additional resources, see alcoholism support group.

Outlook (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.

Possible Complications

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

When to Contact a Medical Professional

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 reduce the use of alcohol. Obtain prompt medical treatment for symptoms of alcohol withdrawal.

For more information see: Alcoholism