eMedicine Specialties > Emergency Medicine > Neurology

Delirium Tremens

Author: William G Gossman, MD, Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Consulting Staff, Department of Emergency Medicine, Creighton University Medical Center
Contributor Information and Disclosures

Updated: Jul 2, 2007

Introduction

Background

Delirium tremens (DT) is a potentially fatal form of ethanol (alcohol) withdrawal. Symptoms of ethanol withdrawal and DT have been recognized for hundreds of years, but the debate over their etiology continued into the 1950s. The work of Victor and Adams as well as Isbell finally demonstrated the symptoms related to ethanol abstinence.

Symptoms may begin a few hours after the cessation of ethanol but may not peak until 48-72 hours. Emergency physicians must recognize that the presenting symptoms may not be severe and identify those at risk for developing DT. For patients in DT, early recognition and therapy are necessary to prevent significant morbidity and death.

Pathophysiology

DT is caused by the direct effect that ethanol has on the benzodiazepine-GABAa-chloride receptor complex. Persistent effects of ethanol lead to the down-regulation of the receptor complex. When ethanol is withdrawn, a functional decrease in the inhibitory neurotransmitter GABA is seen. This results in an unopposed increase in sympathetic activity with a resultant increase in plasma and urinary catecholamines. Ethanol also acts as an N -methyl D-aspartate receptor antagonist. Withdrawal of ethanol leads to increased activity of these excitatory neural receptors.

Frequency

United States

Only 5% of patients with ethanol withdrawal progress to DT.

Mortality/Morbidity

  • The mortality rate may be as high as 35% if untreated but is less than 5% with early recognition and treatment.
  • Patients at greatest risk for death are those with extreme fever, fluid and electrolyte imbalance, or intercurrent illness such as pneumonia, hepatitis, or pancreatitis.

Sex

Approximately 10% of males and 3-5% of females are alcoholic; 5% of each group experiences DT.

Age

Adolescence to late adulthood is typical.

Clinical

History

  • Delirium tremens is more common in patients with a long history of ethanol use and a prior history of significant withdrawal. Manifestations of ethanol withdrawal may start several hours to days after cessation or diminution of ethanol intake. Ethanol withdrawal seizures typically occur 6-48 hours after the last drink. DT usually begins 24-72 hours after cessation or reduction of ethanol use.
  • Diagnosis is made when the course progresses beyond the usual symptoms of withdrawal to include altered mental status (eg, confusion, hallucinations, severe agitation) or generalized seizures. Symptoms may include the following:
    • Tremors
    • Irritability
    • Insomnia
    • Nausea/vomiting (frequently secondary to gastritis or pancreatitis)
    • Hallucinations (auditory, visual, or olfactory)
    • Confusion
    • Delusions
    • Severe agitation
    • Seizures - Begin 6-48 hours after the last drink (Status epilepticus is uncommon in patients with ethanol withdrawal, but ethanol withdrawal is still one of more common causes of status epilepticus.)

Physical

  • Examination findings may be nonspecific. Clinicians should look for stigmata of habitual ethanol use, other potential causes for altered mental status (eg, CNS trauma/infection), and any associated medical problems (eg, hepatitis, pancreatitis, pneumonia).
    • Tachycardia
    • Hyperthermia
    • Hypertension
    • Tachypnea
    • Diaphoresis
    • Tremor
    • Mydriasis
    • Diaphoresis
    • Ataxia
    • Altered mental status
    • Hallucination
    • Cardiovascular collapse

Causes

  • Risk factors for developing DT
    • Ethanol withdrawal seizures
    • Prior history of DT
    • Higher-than-usual quantity and frequency of ethanol consumption (So much individual variability exists that the actual answer may not be clinically relevant.)
  • Associated infections or medical problems (eg, pneumonia, hepatitis, pancreatitis)

More on Delirium Tremens

Overview: Delirium Tremens
Differential Diagnoses & Workup: Delirium Tremens
Treatment & Medication: Delirium Tremens
Follow-up: Delirium Tremens
References

References

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

  2. Hamilton RJ. Substance withdrawal. In: Goldfrank LR, et al, eds. Goldfrank's Toxicologic Emergencies. 6th ed. McGraw-Hill Professional Publishing; 1998:1127-1143.

  3. 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].

  4. 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].

  5. 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].

  6. 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. [Medline].

  7. 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].

  8. 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].

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

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

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

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

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

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

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

  16. 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].

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

Further Reading

Keywords

DT, delirium tremens, ethanol abstinence, rum fits, ethanol withdrawal, ethanol alcohol withdrawal, benzodiazepine-GABAa-chloride receptor complex, ethanol withdrawal seizures, tremors, delusions, severe agitation, seizures, confusion, hallucinations, insomnia, irritability, status epilepticus, habitual ethanol use, alcohol withdrawal

Contributor Information and Disclosures

Author

William G Gossman, MD, Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Consulting Staff, Department of Emergency Medicine, Creighton University Medical Center
William G Gossman, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

William K Chiang, MD, Associate Professor, Department of Emergency Medicine, Department of Emergency Medicine, New York University School of Medicine; Consulting Staff, 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, ABAT, Director of Pharmacy, Sacred Heart Hospital
John T VanDeVoort, PharmD, ABAT is a member of the following medical societies: American Academy of Clinical Toxicology and American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

J Stephen Huff, MD, Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health System
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 Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School
John Halamka, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Program Director, Department of 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.