delirium tremens (DT's)

Introduction

Is a serious, potentially fatal complication of alcohol withdrawal syndrome.

Epidemiology

• 5% of patients hospitalized for alcohol withdrawal

Clinical manifestations

• onset:
  • may begin as early as 1-3 days after EtOH cessation
  • 48-96 hours after last drink
  • peak incidence in 4-5 days
• gross tremors
• seizures
• incontinence
• frightening visual hallucinations
• ataxia
• vestibular dysfunction
• autonomic lability
  • diaphoresis
  • tachycardia
  • hyperthermia
  • anxiety
  • insomnia
  • mydriasis
• delirium
  • confusion
  • depression
• progressively worsening shakiness, diaphoresis, palpitations, & confusion (MKSAP20)

Laboratory

• complete blood count (CBC) with differential
• serum chemistries
  • chem 7
  • Ca+2, Mg+2
  • liver function tests
  • folate/B12
  • amylase
  • stool guaiac
• PT/aPTT, INR
• hepatitis serologies (B & C)
• urinalysis
• urine toxicology
• CSF analysis

Diagnostic procedures

• electrocardiogram
• electroencephalogram

Radiology

• chest X-ray
• computed tomography (CT) of head
• upper GI series

Management

• transfer to the ICU & sedate +/- mechanical ventilation for combativeness, agitation & confusion not responding to benzodiazepine or antipsychotic
• vitals every 6 hours
• low stimulation environment
• rehydration
• pharmaceutical agents
  • benzodiazepines
    • lorazepam or oxazepam if liver disease
  • haloperidol* for psychosis
• prognosis
  • generally clear in 12-24 hours
  • 20% mortality without treatment; 1% with appropriate therapy

* Caution: neuroleptics can decrease the threshold for seizures

More general terms

• alcohol withdrawal syndrome