eMedicine Specialties > Emergency Medicine > Neurology

Delirium Tremens: Follow-up

Author: Anne Yim, MD, Resident Physician, Department of Emergency Medicine, Kings County Hospital and State University of New York Downstate Medical Center
Coauthor(s): Sage W Wiener, MD, Assistant Professor, Department of Emergency Medicine, State University of New York Downstate, Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Oct 6, 2009

Follow-up

Further Inpatient Care

  • Admit all patients with delirium tremens (DT) to the ICU.
  • Continue pharmacological sedation in a symptom-triggered dosing regimen.
  • Continue antibiotics if indicated.

Further Outpatient Care

  • Outpatient management does not have a role in the treatment of delirium tremens (DT).
  • Refer patients for alcohol rehabilitation upon discharge.

Deterrence/Prevention

  • Upon discharge, patients should be counseled to abstain from alcohol.
  • Consider referral to inpatient detoxification or alcohol rehabilitation program.
  • Various types of outpatient programs are available.
    • The Substance Abuse and Mental Health Services Administration (SAMHSA) of the US Department of Health and Human Services offers an extensive listing of drug and alcohol treatment facilities by location. SAMHSA helpline: (800) 662-HELP (4357) with help in English and Spanish, or TDD at (800) 487-4889.
    • Alcoholics Anonymous
  • Encourage support from family and friends.

Complications

  • Oversedation
  • Respiratory depression, respiratory arrest, intubation
  • Aspiration pneumonitis
  • Cardiac arrhythmias

Prognosis

  • Mortality rate of delirium tremens (DT) is up to 35% untreated, and less than 5% with treatment.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose such conditions as hypoglycemia, trauma, pancreatitis, and infections
  • Failure to administer thiamine in patients presenting with alcohol withdrawal
  • Failure to use adequate chemical sedation with use of physical restraints
  • Masking of withdrawal signs with sympatholytics while failing to treat the underlying withdrawal
  • Failure to consider diagnosis of withdrawal in patients with abnormal vital signs, altered mental status, or single simple seizure
  • Failure to admit patients with signs of major withdrawal or delirium tremens (DT)

Special Concerns

  • Large amounts of sedatives may be required to achieve adequate control of symptoms. Sometimes, the airway must be controlled to permit the safe administration of adequate doses of sedatives.
  • Concurrent illnesses such as pneumonia, pancreatitis, hepatitis, and trauma should be identified and treated.
  • Anticonvulsant therapy is not indicated for ethanol withdrawal seizures. Treat with agents that act on the GABA receptor—benzodiazepines, barbiturates, or propofol.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, William G Gossman, MD, to the development and writing of this article.



More on Delirium Tremens

Overview: Delirium Tremens
Differential Diagnoses & Workup: Delirium Tremens
Treatment & Medication: Delirium Tremens
Follow-up: Delirium Tremens
References
[ CLOSE WINDOW ]

References

  1. Sutton T. Tracts on delirium tremens, on peritonitis, and on some other inflammatory affections, and on the gout. 1813.

  2. Victor M, Adams RD. The effect of alcohol on the nervous system. Res Publ Assoc Res Nerv Ment Dis. 1953;32:526-73. [Medline].

  3. Chan GM, Hoffman RS, Gold JA, Whiteman PJ, Goldfrank LR, Nelson LS. Racial variations in the incidence of severe alcohol withdrawal. J Med Toxicol. Mar 2009;5(1):8-14. [Medline].

  4. [Guideline] Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. Jul 9 1997;278(2):144-51. [Medline].

  5. Daeppen JB, Gache P, Landry U, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. May 27 2002;162(10):1117-21. [Medline].

  6. 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].

  7. Hayner CE, Wuestefeld NL, Bolton PJ. Phenobarbital treatment in a patient with resistant alcohol withdrawal syndrome. Pharmacotherapy. Jul 2009;29(7):875-8. [Medline].

  8. Caetano R, Clark CL, Greenfield TK. Prevalence, trends, and incidence of alcohol withdrawal symptoms: analysis of general population and clinical samples. Alcohol Health Res World. 1998;22(1):73-9. [Medline].

  9. Chiang C. Withdrawal Syndromes. In: Ford MD, et al. Clinical Toxicology. 1. WB Saunders Company; 2001.

  10. Coomes TR, Smith SW. Successful use of propofol in refractory delirium tremens. Ann Emerg Med. Dec 1997;30(6):825-8. [Medline].

  11. Ferguson JA, Suelzer CJ, Eckert GJ, Zhou XH, Dittus RS. Risk factors for delirium tremens development. J Gen Intern Med. Jul 1996;11(7):410-4. [Medline].

  12. Fiellin DA, O'Connor PG, Holmboe ES, Horwitz RI. Risk for delirium tremens in patients with alcohol withdrawal syndrome. Subst Abus. Jun 2002;23(2):83-94. [Medline].

  13. Girard DE, Kumar KL, McAfee JH. Alcohol intoxication and withdrawal. Med Rounds. 1988;1:158-164.

  14. Grant BF et al. The 12-Month Prevalence and Trends in DSM–IV Alcohol Abuse and Dependence: United States, 1991–1992 and 2001–2001. Drug and Alcohol Dependence. 2004;74 (3):223-234.

  15. Hamilton RJ. Substance Withdrawal. In: Goldfrank LR, et al. Goldfrank's Toxicologic Emergencies. 7. McGraw-Hill Professional Publishing; 2002:1059-1073.

  16. Hodges B, Mazur JE. Intravenous ethanol for the treatment of alcohol withdrawal syndrome in critically ill patients. Pharmacotherapy. Nov 2004;24(11):1578-85. [Medline].

  17. Isbell H, Fraser HF, Wikler A, Belleville RE, Eisenman AJ. An experimental study of the etiology of rum fits and delirium tremens. Q J Stud Alcohol. Mar 1955;16(1):1-33. [Medline].

  18. Klijn IA, van der Mast RC. Pharmacotherapy of alcohol withdrawal delirium in patients admitted to a general hospital. Arch Intern Med. Feb 14 2005;165(3):346. [Medline].

  19. Kumar S, Fleming RL, Morrow AL. Ethanol regulation of gamma-aminobutyric acid A receptors: genomic and nongenomic mechanisms. Pharmacol Ther. Mar 2004;101(3):211-26. [Medline].

  20. [Guideline] 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].

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

  22. Moore M, Gray MG. Delirium tremens: A study of cases at the Boston City Hospital, 1915-1936. N Engl J Med. Feb 14 2005;220:953-956.

  23. Roffman JL, Stern TA. Alcohol withdrawal in the setting of elevated blood alcohol levels. Prim Care Companion J Clin Psychiatry. 2006;8(3):170-3. [Medline].

  24. Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard DR, Calkins DR. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA. Aug 17 1994;272(7):519-23. [Medline].

  25. Schuckit MA. Alcoholism and drug dependency. In: Harrison's Principles of Internal Medicine. 1991:2146-2151.

  26. Shabbir HF, Ilksoy N, Greenwald JL. Alcohol Withdrawal Syndromes. In: Williams MV, et al. Comprehensive Hospital Medicine: An Evidence Based Approach. 1. WB Saunders; 2007.

  27. Tan CY, Weaver DF. Molecular pathogenesis of alcohol withdrawal seizures: the modified lipid-protein interaction mechanism. Seizure. Aug 1997;6(4):255-74. [Medline].

  28. Trevisan LA, Boutros N, Petrakis IL, Krystal JH. Complications of alcohol withdrawal: pathophysiological insights. Alcohol Health Res World. 1998;22(1):61-6. [Medline].

  29. Tsai G, Gastfriend DR, Coyle JT. The glutamatergic basis of human alcoholism. Am J Psychiatry. Mar 1995;152(3):332-40. [Medline].

  30. Wasilewski D, Matsumoto H, Kur E, et al. Assessment of diazepam loading dose therapy of delirium tremens. Alcohol Alcohol. May 1996;31(3):273-8. [Medline].

  31. Wax PM. Withdrawal syndromes. In: The Clinical Practice of Emergency Medicine. 2nd ed. 1996:1434-1439.

  32. Wright T, Myrick H, Henderson S, Peters H, Malcolm R. Risk factors for delirium tremens: a retrospective chart review. Am J Addict. May-Jun 2006;15(3):213-9. [Medline].

  33. Zaloga GP. Alcohol withdrawal syndrome medications. In: The Critical Care Drug Handbook. 1991:40-45.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

DT, delirium tremens, delirium tremens symptoms, alcohol withdrawal delirium, alcohol withdrawal hallucinosis, ethanol abstinence, rum fits, ethanol withdrawal, ethanol alcohol withdrawal, ethanol withdrawal seizures

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

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.

Coauthor(s)

Sage W Wiener, MD, Assistant Professor, Department of Emergency Medicine, State University of New York Downstate, 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.

Medical Editor

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.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & 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.

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

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

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.