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 When ethanol is withdrawn, a functional decrease in the inhibitory neurotransmitter GABA is seen.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 |
| Next Page » |
References
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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
