Delirium tremens overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2] Zehra Malik, M.B.B.S[3]
Overview
Alcohol has a depressant effect on the brain and nervous system. If alcohol is stopped abruptly after a long period of chronic usage, the brain and nervous system struggle to recalibrate which leads to overstimulation of the brain. Delirium tremens (colloquially, the DTs, "the horrors", "the shakes" or "rum fits"; afflicted individuals referred to as "jitterbugs" in 1930s Harlem slang; literally, "shaking delirium" or "trembling madness" in Latin) is an acute episode of delirium that is usually caused by withdrawal or abstinence from alcohol following habitual excessive drinking, or benzodiazepines or barbiturates (and other minor tranquilizers).When caused by alcohol, it occurs only in individuals with a history of constant, long-term alcohol consumption. Occurrence due to benzodiazepine or barbiturate withdrawal does not require as long a period of consistent intake of such drugs. Prior use of both tranquilizers and alcohol can compound the symptoms, and while extremely rare, is the most dangerous especially if untreated. Barbiturates are generally accepted as being extremely dangerous, both due to overdose potential and addiction potential including the extreme withdrawal syndrome that usually is marked by delirium tremens upon discontinuation. Due to this, barbiturates are rarely used anymore, being replaced by the generally accepted less dangerous benzodiazepines, which however still cause a similar withdrawal syndrome. Five percent of acute ethanol withdrawal cases progress to delirium tremens.Unlike the withdrawal syndrome associated with opiate addiction (generally), delirium tremens (and alcohol withdrawal in general) can be fatal. Mortality can be up to 35% if untreated; if treated early, death rates range from 5-15%.
Historical Perspective
Classification
There is no established system for the classification of Delirium tremens.
Pathophysiology
Causes
The most common cause of delirium tremens is abrupt alcohol cessation in chronic alcohol abusers.
Differentiating Delirium tremens from Other Diseases
Epidemiology and Demographics
Five percent of acute ethanol withdrawal cases progress to delirium tremens. Unlike the withdrawal syndrome associated with opiate addiction (generally), delirium tremens (and alcohol withdrawal in general) can be fatal. Mortality can be up to 35% if untreated; if treated early, death rates range from 5-15%.
Risk Factors
Common risk factors in the development of Delirium tremens include chronic alcoholism, more days since last alcohol consumption, prior history of Delirium tremens, and extreme withdrawal symptoms.
Screening
Screening tools include the Alcohol Use Disorders Identification Test (AUDIT) and the CAGE screening test.
Natural History, Complications, and Prognosis
The symptoms of Delirium tremens usually start within 48 to 98 hours after the last drink in long term alcoholics. In some cases, it may occur up to 7 to 10 days after their last drink. Delirium tremens have a very high mortality rate if left untreated. Complications include, hypertension, hyperthermia, Heart attack, cardiac arrhythmia, stroke, seizure, respiratory failure, altered mental status, rhabdomyolysis and death. Prognosis largely depends upon early recognition and intervention. Mortality from Delirium tremens has been reduced from 35% to 5-15% due to early diagnosis and advanced ICU arrangements. Due to advanced treatment overall mortality is low, but it can vary in patient with other comorbidities including pulmonary insufficiencies, arrhythmia, pancreatitis, or if patient is older.
Diagnosis
Diagnostic Study of Choice
History and Symptoms
The hallmark of delirium tremens is tremor, confusion, disorientation, agitation, signs of severe autonomic instability (fever, tachycardia, hypertension) with a positive history of alcohol cessation 48 - 72hrs prior in a patients with history of chronic alcohol abuse.
Physical Examination
Patients with delirium tremens usually appear diaphoretic, confused and agitated. Although there are no physical findings diagnostic of delirium tremens, patients may present with fever, tachycardia, high blood pressure, tachypnea, altered mental status, mydriasis, positional nystagmus, and tremor.
Laboratory Findings
Laboratory findings consistent with the diagnosis of delirium tremens include hypoglycemia, hypomagnesemia, hypophosphatemia, and severe dehydration.
Electrocardiogram
Tachyarrhythmias are common ECG findings in patients with delirium tremens. Torsade de pointes can occur as prolonged QTc interval is strongly associated with heavy alcohol consumption.
X-ray
An x-ray is important in patients with suspected delirium tremens, especially if they present with a fever or trauma. A chest x-ray should be obtained in patients with fever, as fifty-percent of these patients may have an infection. Pneumonia is the most common infection.
Echocardiography and Ultrasound
There are no echocardiography/ultrasound findings associated with delirium tremens. Due to the stress induced by delirium tremens, few cases of Takotsubo cardiomyopathy have been reported.
CT scan
A head CT scan should be performed to evaluate any intracranial pathology or to identify a head injury that may have triggered the tremors in a patient with a history of chronic alcohol abuse.
MRI
There are no MRI findings associated with delirium tremens. MRI can show signs of Wernicke's Encephalopathy in a patient with chronic alcohol abuse.
Other Imaging Findings
There are no other imaging findings associated with delirium tremens.
Other Diagnostic Studies
Treatment
Medical Therapy
The mainstay of delirium tremens treatment is supportive care and sedatives. Benzodiazepines are the initial choice for sedation. To establish a consistent serum level, long-acting benzodiazepines such as diazepam and chlordiazepoxide are favored over short-acting benzodiazepines.
Interventions
Surgery
There is no surgical intervention for delirium tremens.
Primary Prevention
There are no established measures for the primary prevention of delirium tremens other than to avoid or reduce the use of alcohol.
Secondary Prevention
Effective measures for the secondary prevention of delirium tremens include early detection of symptoms, prompt treatment, CAGE assessment, and proper counseling to reduce alcohol consumption.