Delirium Tremens (DTs) Clinical Presentation

  • Author: Michael James Burns, MD, FACEP, FACP; Chief Editor: Michael R Pinsky, MD, CM, FCCP, FCCM   more...
 
Updated: Jun 29, 2011
 

History

Alcohol withdrawal syndrome is the clinical syndrome that occurs when people who are physically dependent upon alcohol stop drinking or reduce their alcohol consumption.

Alcohol withdrawal syndrome is divided into 4 categories:

  • Minor withdrawal
  • Major withdrawal
  • Withdrawal seizures
  • Delirium tremens (DTs)

Minor withdrawal

Minor withdrawal (withdrawal tremulousness) occurs within 6-24 hours following the patient’s last drink and is characterized by tremor, anxiety, nausea, vomiting, and insomnia.

Major withdrawal

Major withdrawal (hallucinations) occurs 10-72 hours after the last drink. The signs and symptoms include visual and auditory hallucinations, whole body tremor, vomiting, diaphoresis, and hypertension.

Withdrawal seizures

Withdrawal seizures (rum fits) occur within 6-48 hours of alcohol cessation; they are major motor seizures that take place during withdrawal in patients who normally have no seizures and have normal electroencephalograms (EEGs). These seizures are typically generalized and brief. In the absence of treatment, multiple seizures occur in 60% of patients, but the duration between the first and last seizure is usually less than 6 hours. Only 3% of patients go on to develop status epilepticus.

An alcohol withdrawal seizure is frequently the first sign of alcohol withdrawal, and no other signs of withdrawal may be present after the seizure abates. About 30-40% of patients with alcohol withdrawal seizures progress to DTs.

Alcohol withdrawal seizures usually occur only once or recur only once or twice, and they generally resolve spontaneously. If a patient has seizures that are not typical of alcohol withdrawal seizures (such as partial or focal seizures, prolonged seizures, or seizures with a prolonged postictal state) or has signs of significant head trauma, then the underlying cause of the seizure should be investigated. Alcohol-dependent patients have increased rates of idiopathic epilepsy, traumatic brain injury, stroke, and intracranial mass lesions. Moreover, seizures in alcohol-dependent patients may be caused by concomitant use of stimulant drugs, such as cocaine or amphetamines, or by withdrawal from sedative agents, such as benzodiazepines or barbiturates.

Delirium tremens

DTs is the most severe manifestation of alcohol withdrawal. It occurs 3-10 days following the last drink. Clinical manifestations include agitation, global confusion, disorientation, hallucinations, fever, hypertension, diaphoresis, and autonomic hyperactivity (tachycardia and hypertension).

CIWA-Ar scale

The most objective and best-validated tool to assess the severity of alcohol withdrawal is the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar).[2] This survey consists of 10 items and can be administered rapidly at the bedside. The 10 items include nausea and vomiting, anxiety, tremor, sweating, auditory disturbances, visual disturbances, tactile disturbances, headache, agitation, and clouding of sensorium. Zero to 7 points are assigned to each item, except for the last item, which is assigned 0-4 points, with a total possible score of 67.

This scale has been demonstrated to have high reliability, reproducibility, and validity, based on comparisons with ratings by experienced clinicians, and has been shown to be usable in detoxication units, psychiatry units, and hospital medical/surgical wards.

The CIWA-Ar scale is intended only for patients who have been drinking recently. It relies on patients’ ability to respond to questions about their symptoms. Patients must be able to communicate and have a clear enough sensorium to reply logically, because many of the items require coherent answers. The CIWA-Ar scale has not been validated in complex medical patients, postsurgical patients, and critically ill patients.

A score of greater than 15 is seen in patients with moderate to severe alcohol withdrawal. Patients with a score of greater than 15 or those who have a history of alcohol withdrawal seizures should be treated with medication upon presentation. These patients need to be monitored carefully for the development of DTs. Patients with a score of 8-15, who have mild alcohol withdrawal, should probably also receive drug treatment. Careful and frequent monitoring with the CIWA-Ar is particularly helpful in patients receiving treatment with symptom-triggered drug therapy (also known as prn therapy).

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Physical Examination

No specific findings on physical examination are diagnostic for delirium tremens (DTs). However, DTs often presents with a coexisting illness, so a careful physical examination should be performed in order to uncover any potentially serious illness that may be present. The patient should be assessed for stigmata of chronic liver disease. A search for signs of trauma should also be included.

Clinical findings associated with DTs may include the following:

  • Tachycardia
  • Hyperthermia
  • Hypertension
  • Tachypnea
  • Diaphoresis
  • Tremor
  • Mydriasis
  • Altered mental status
  • Severe psychomotor agitation
  • Fever
  • Positional nystagmus
  • Global confusion
  • Disorientation
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Contributor Information and Disclosures
Author

Michael James Burns, MD, FACEP, FACP  Health Science Clinical Professor, Department of Emergency Medicine, Department of Internal Medicine, Division of Infectious Diseases, University of California Irvine School of Medicine

Michael James Burns, MD, FACEP, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American College of Physicians, American Society of Tropical Medicine and Hygiene, California Medical Association, Infectious Diseases Society of America, Phi Beta Kappa, Royal Society of Tropical Medicine and Hygiene, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

William K Chiang, MD  Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center

William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

J Stephen Huff, MD  Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Michael E Lekawa, MD, FACS  Associate Clinical Professor of Surgery, University of California, Irvine School of Medicine; Chief, Department of Surgery, Division of Trauma and Critical Care, Director of Trauma Services, Director of Surgical Intensive Care Unit, Director of Student Critical Care Teaching Program, Medical Director of Surgery Clinics, University of California, Irvine Medical Center

Michael E Lekawa, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

James B Price, MD  Attending Emergency Physician, Mission Hospital; Clinical Faculty, Department of Emergency Medicine, Harbor-UCLA Medical Center

James B Price, MD is a member of the following medical societies: Alpha Omega Alpha and American College of Emergency Physicians

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Sage W Wiener, MD  Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Assistant Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Anne Yim, MD  Resident Physician, Department of Emergency Medicine, Kings County Hospital and State University of New York Downstate Medical Center

Anne Yim, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Lisa Kirkland, MD, FACP, CNSP, MSHA  Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital

Lisa Kirkland, MD, FACP, CNSP, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, and Society of Hospital Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold L Manning, MD  Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School

Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM  Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center

Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, European Society of Intensive Care Medicine, Shock Society, and Society of Critical Care Medicine

Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author William G Gossman, MD, to the development and writing of a source article.

References

  1. Chan GM, Hoffman RS, Gold JA, et al. Racial variations in the incidence of severe alcohol withdrawal. J Med Toxicol. Mar 2009;5(1):8-14. [Medline].

  2. Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. Nov 1989;84(11):1353-7. [Medline].

  3. Krishel S, SaFranek D, Clark RF. Intravenous vitamins for alcoholics in the emergency department: a review. J Emerg Med. May-Jun 1998;16(3):419-24. [Medline].

  4. [Guideline] Gold JA, Rimal B, Nolan A, Nelson LS. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. Mar 2007;35(3):724-30. [Medline].

  5. Weinberg JA, Magnotti LJ, Fischer PE, et al. Comparison of intravenous ethanol versus diazepam for alcohol withdrawal prophylaxis in the trauma ICU: results of a randomized trial. J Trauma. Jan 2008;64(1):99-104. [Medline].

  6. McCowan C, Marik P. Refractory delirium tremens treated with propofol: a case series. Crit Care Med. Jun 2000;28(6):1781-4. [Medline].

  7. Hendey GW, Dery RA, Barnes RL, Snowden B, Mentler P. A prospective, randomized, trial of phenobarbital versus benzodiazepines for acute alcohol withdrawal. Am J Emerg Med. May 2011;29(4):382-5. [Medline].

  8. Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med. Jul 12 2004;164(13):1405-12. [Medline].

  9. Jaeger TM, Lohr RH, Pankratz VS. Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients. Mayo Clin Proc. Jul 2001;76(7):695-701. [Medline].

 
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