Delirium tremens, also known as withdrawal delirium, is overactivity of the central nervous system after cessation of alcohol intake. The time interval is variable; it usually occurs within 1 wk after reduction or cessation of heavy alcohol intake and persists for 1 to 3 days.

Withdrawal delirium

Alcohol withdrawal syndrome

DTs

Alcoholic delirium

• Ethanol withdrawal symptoms usually begin within 8 h after blood alcohol levels decrease, peak at about 72 h, and are markedly reduced by days 5 to 7 of abstinence
• Initially: Anxiety, insomnia, tremulousness
• Early: Tachycardia, sweating, anorexia, agitation, headache, gastrointestinal distress
• Late: Seizures, visual hallucinations, delirium

Alcoholism

• Coexisting illness
• Trauma
• Drug use
• Box E1 summarizes illnesses not to be missed in the person presumed to be intoxicated

• Frequent rating of symptoms (hallucinations, tremor, sweating, agitation, orientation)
• The Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale can be used to measure the severity of alcohol withdrawal. It consists of the 10 following items:
  1. Nausea
  2. Tremor
  3. Autonomic hyperactivity
  4. Anxiety
  5. Agitation
  6. Tactile disturbances
  7. Visual disturbances
  8. Auditory disturbances
  9. Headache
  10. Disorientation

The maximum score is 67. Scores <8 indicate mild symptoms, scores 8 to 15 indicate moderate withdrawal symptoms, and scores >15 indicate severe withdrawal symptoms.

• Electrolytes (including magnesium, phosphate)
• Close monitoring of glucose levels
• Drug screen (blood and urine)

Computed tomography (CT) scan of head if there is a history of head trauma.

Refer to drug rehabilitation program after patient recovers.

• Admission to a detoxification unit where patient can be observed closely.
• Vital signs q30min initially (neurologic signs, if necessary).
• Use of lateral decubitus or prone position if restraints are necessary.
• Nothing by mouth: Nasogastric tube for abdominal distention may be necessary but should not be routinely used.
• Vigorous hydration (4 to 6 L/day): Intravenous (IV) with glucose (Na⁺, K⁺, PO₄^3–, and Mg²⁺ replacement). May be necessary in some patients, but commonly there is little support for routine administration of magnesium. Use vigorous hydration with caution in patients with congestive heart failure.
• Vitamins: Thiamine 500 mg infused IV over the course of 30 min daily for 3 days. The initial dose of thiamine should precede the administration of IV dextrose; multivitamins (may be added to the hydrating solution).
• Sedation (sedation can be achieved using fixed-dose regimen or individualized benzodiazepine administration:
  1. Initially: Lorazepam 8 mg intramuscular (IM)/IV every 15 minutes as needed, after the patient has received 16 mg. If delirium is still severe, administer an 8 mg bolus IV, then administer 10 to 30 mg/hr.
  2. Maintenance (individualized dosage): Chlordiazepoxide, 50 to 100 mg PO q4 to 6h, lorazepam 2 mg PO q4h, or diazepam 5 to 10 mg PO tid; withhold doses or decrease subsequent doses if signs of oversedation are apparent.
  3. Midazolam is also effective for managing DTs. Its rapid onset (sedation within 2 to 4 min of IV injection) and short duration of action (approximately 30 min) make it an ideal agent for titration in continuous infusion.
• In addition to benzodiazepines, administer medications such as the antipsychotic agent haloperidol for uncontrolled agitation or hallucinations (0.5 to 5 mg IV/IM every 30 to 60 min as needed for severe agitation or hallucinations, not to exceed 20 mg).
• Treatment of seizures: Diazepam 2.5 mg/min IV until seizure is controlled (check for respiratory depression or hypotension) may be beneficial for prolonged seizure activity; IV lorazepam 1 to 2 mg q2h can be used in place of diazepam. In general, withdrawal seizures are self-limited, and treatment is not required; the use of phenytoin or other anticonvulsants for short-term treatment of alcohol withdrawal seizures is not recom-mended.
• Diagnosis and treatment of concomitant medical, surgical, or psychiatric conditions.

Alcoholics Anonymous has the best record in breaking addiction, but the results are still disappointing.

Refer to drug rehabilitation program

If cardiac arrhythmias are prominent or respiratory distress develops

This is a potentially lethal disease if not carefully treated. Mortality rate is 15% in untreated patients, and approximately 1% to 6% of hospitalized patients who have withdrawal delirium die.

Delirium Tremens (Patient Information)

Alcohol Use Disorder (Related Key Topic)

Delirium (Related Key Topic)

Wernicke Syndrome (Related Key Topic)