What Is Delirium Tremens?

Delirium Tremens (DTs): Causes, Symptoms, And Treatment

What Is Delirium Tremens?

Delirium tremens, often called DTs, is the most severe symptom associated with alcohol withdrawal. When someone drinks heavily, their body becomes dependent on alcohol in order to function; if alcohol use stops suddenly, acute withdrawal symptoms delirium tremens may occur. DTs may be referred to as alcohol withdrawal delirium, or “having the shakes.”

What Are Delirium Tremens (DTs)?

DTs are characterized by a serious onset of symptoms, including extreme confusion, seizures, or mental disturbance. Researchers estimate that 50 percent of those suffering from alcohol abuse will exhibit alcohol withdrawal symptoms if they decrease their usage, and between three and five percent will experience DTs.

What Causes Delirium Tremens (DTs)?

Delirium tremens can occur when someone with heavy alcohol use stops drinking suddenly. Heavy alcohol consumption, especially over a length of time, can lead to a host of medical issues, in addition to DTs.

The Center for Disease Control and Prevention defines excessive drinking as consuming 15 drinks per week for men, and 8 drinks per week for women. Some individuals may not understand what constitutes a standard drink, thereby minimizing their actual alcohol consumption.

A standard drink refers to:

  • 12 ounces of regular beer
  • 8 ounces of malt liquor
  • 5 ounces of wine
  • 5 ounces of distilled spirits or liquor

Alcohol use interferes with the way the body regulates GABA, an essential neurotransmitter. The body may mistake alcohol for GABA, and stop production of GABA as a result. If someone struggling with heavy alcohol use stops drinking, their body believes there is not enough GABA to function, which can lead to symptoms associated with delirium tremens.

Additional risk factors for developing delirium tremens include:

  • Drinking history: Those with a history of alcohol withdrawal are at an increased risk of DTs. If someone drinks heavily and quits multiple times, they may have experienced multiple instances of alcohol withdrawal.
  • Length of alcohol use: Those who have been drinking heavily for a period of 10 years or more are at an increased risk for DTs.
  • Malnutrition: Individuals with heavy alcohol usage may have replaced food with alcohol, leading to a higher risk of delirium tremens.
  • Medical complications: Those who have a history of seizures, or are currently battling an illness or infection, are at a greater risk for DTs.
  • Age and gender: Older adult men have the highest prevalence of delirium tremens.
  • Ethnicity and race: Research indicates that Caucasian men are more ly to develop DTs.

Symptoms Of Delirium Tremens (DTs)

DTs can begin as early as 48 hours after abrupt alcohol cessation and can last up to five days. If treatment is not sought, this condition is associated with a 37 percent mortality rate. Delirium tremens is a medical emergency, and knowing the symptoms of DTs can save someone’s life. If someone experiences any of these symptoms, call 911 immediately.

Some of the symptoms of delirium tremens include:

  • agitation
  • body tremors
  • confusion
  • change in mental ability
  • disorientation
  • irregular heartbeat
  • trouble breathing
  • hallucinations
  • stomach pain
  • sensitivity to light and sound
  • mood swings
  • restlessness
  • extreme fatigue
  • change in attention span
  • delusion (believing irrational things)
  • delirium (extreme mental disturbance)
  • seizure

Diagnosis And Treatment of Delirium Tremens (DTs)

Delirium tremens affect thousands of Americans every year. Alcohol is the most commonly abused drug in the U.S., and DTs affects three to five percent of those suffering from alcohol abuse.

Alcohol is the third leading preventable cause of death in the U.S., and every year, an estimated 88,000 people die from alcohol-related health issues DTs. Because DTs can be difficult to manage, the medical community now focuses on preventing DTs with routine alcohol screenings.

Diagnosis of DTs can be completed by a healthcare professional, and will ly include a physical exam to check for fever, dehydration, tremors, and irregular heartbeat. The physician may ask questions regarding the patient’s history with alcohol and alcohol withdrawal.

If you or someone close to you is exhibiting signs of delirium tremens, seek medical attention immediately. Hospitals and emergency response teams are equipped to treat DTs through the use of medication benzodiazepines, in order to sedate and stabilize the patient. Being in a medical setting allows healthcare providers to monitor the patient, preventing further any complication.

Treatment For Alcohol Abuse And Addiction

While many people attempt to detox from alcohol at home, this can be extremely dangerous. Alcohol withdrawal and DTs can be life-threatening and should be supervised in a medical setting. Fortunately, there is treatment available throughout the U.S., including detox programs and addiction rehab centers.

Once someone has successfully detoxed from alcohol, they are encouraged to explore options for entering an alcohol treatment center. Private insurance and public assistance programs help ensure that affordable, effective treatment is available to all.

For more information on preventing delirium tremens, or to learn more about treatment options near you, contact us today.

Источник: https://vertavahealth.com/alcohol/delirium-tremens/

Dealing with the DTs

What Is Delirium Tremens?

Irritability. Tremors. Sweating and a rapid heart rate. Extreme confusion. Fever. Convulsions. These are all symptoms of acute alcohol withdrawal syndrome. A patient may develop acute alcohol withdrawal syndrome when chronic alcohol use is interrupted by hospital admission. Increasingly patients are being treated for alcohol withdrawal on general medical wards.

Acute withdrawal is most safely managed in an inpatient setting if the patient has been using high doses of sedatives, has a history of seizures or delirium tremens, or has co-morbid medical or psychiatric problems.1 The severity of the withdrawal syndrome is affected by concurrent medical illness.

Up to 20% of patients develop delirium tremens if left untreated.2 Recognition and effective treatment of alcohol withdrawal are needed to prevent excess mortality or prolonged hospitalization due to complications.

It is essential for hospitalists to recognize and effectively treat acute alcohol withdrawal to prevent adverse outcomes in hospitalized patients.

Acute withdrawal is most safely managed in an inpatient setting if the patient has been using high doses of sedatives, has a history of seizures or delirium tremens, or has comorbid medical or psychiatric problems.

Development of Withdrawal

Hospitalized patients may not be forthcoming about their alcohol consumption for numerous reasons. They may not consider it a problem; they may not recognize that acute withdrawal is a serious and even fatal complication; or they may wish to conceal their alcoholism from family and physicians due to concerns about stigmatization.

Even when patients acknowledge their drinking, they often underestimate the amount, which may be because a patient is minimizing or because alcohol is an amnestic agent, causing drinkers to lose count of how much they have had to drink. It is simplest to ask—in a nonjudgmental manner—all patients admitted to the hospital about drinking and to be alert for signs of acute alcohol withdrawal in all patients.

Not all patients who drink alcohol will develop an acute withdrawal syndrome. Those who drink less frequently—only on weekends with no drinking at all on weekdays, for example—are at lower risk of acute withdrawal. Those who drink on most days of the week are more ly—due to tolerance—to develop withdrawal.

Even a habit of two or three drinks each day is enough to set up a person for withdrawal. Not all daily drinkers are guaranteed to develop withdrawal, and it is difficult to predict who will and who will not.

The best predictor of whether a patient will develop acute withdrawal while hospitalized is a past history of acute alcohol withdrawal.

The alcohol withdrawal syndrome has two phases: early withdrawal and late withdrawal. (See Table 1, below.) The signs and symptoms of early withdrawal usually occur within 48 hours of the last drink. The initial indication is an elevation of vital signs: heart rate, blood pressure, and temperature.

Tremors develop next—first a fine tremor of the hands and fasciculation of the tongue, then gross tremors of the extremities. As the syndrome progresses, disorientation and mild hallucinations (often auditory but occasionally visual) develop, accompanied by diaphoresis.

Seizures are an early sign of alcohol withdrawal and may even be the presenting symptom.

Late alcohol withdrawal is also known as delirium tremens—the DTs—and consists of the worsening autonomic dysregulation that is responsible for the morbidity and mortality attributed to alcohol withdrawal. It begins after early withdrawal—usually 72 hours or more after the last drink.

Some patients do not progress from early to late withdrawal, and their symptoms simply subside after a few days, with or without treatment. But it is impossible to predict which patients will progress and which will not.

The signs of late withdrawal consist of worsening diaphoresis, nausea, and vomiting (which may result in aspiration pneumonia), delirium with frank hallucinations, and rapid, severe fluctuation in vital signs.

Sudden changes in blood pressure and heart rate may result in complications such as myocardial infarction or a cerebrovascular event. Untreated late withdrawal results in significant morbidity and even death.3 Adequate treatment of early withdrawal prevents progression to late withdrawal.


When you or a colleague suspect that a hospitalized patient may develop alcohol withdrawal, regularly assess the patient for signs of early withdrawal.

Use a validated assessment scale to quantify the severity of the withdrawal syndrome, and initiate treatment decisions such as the dose of medication. If no withdrawal signs manifest after 48 hours, then it is usually safe to discontinue monitoring for withdrawal.

Monitor patients for whom alcohol withdrawal is not considered but who then develop withdrawal signs using an assessment scale.

The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is commonly used to assess severity of withdrawal.4 Competent nurses can give it in less than five minutes.

A CIWA-Ar score less than 5 indicates minimal withdrawal with no need for pharmacotherapy, whereas a score that falls in the range of 6-19 indicates mild withdrawal that may benefit from medical treatment.

A score greater than 30 indicates severe withdrawal that requires close monitoring due to the risk for complications such as seizures and autonomic instability.5

The CIWA-Ar is just as useful for evaluating and treating withdrawal in hospitalized patients on general medical wards as it is for use in chemical dependency units. It can also be used to determine an appropriate pharmacotherapy dose for patients in withdrawal who also have other medical illnesses.6

Monitor patients every few hours, with the frequency of evaluation varying by severity of withdrawal signs.

Every four hours is sufficient for most patients, but those who have developed late withdrawal or those with CIWA-Ar scores greater than 30 should be monitored hourly to prevent complications.

Continue regular assessment until the withdrawal syndrome has been under control (CIWA-Ar score less than 6) for at least 24 hours.


Medications: Pharmacotherapy is indicated for the management of moderate to severe withdrawal. Any cross-tolerant medication may be used; benzodiazepines or barbiturates are most commonly prescribed.

It is inappropriate to use beverage alcohol to prevent or treat alcohol withdrawal. Use of intravenous alcohol infusion is reserved for poisoning with methanol, isopropanol, or ethylene glycol.

It should not be given for treatment of acute alcohol withdrawal due to potential complications such as intoxication with delirium and development of gastritis.

Both benzodiazepines and barbiturates, which are different classes of sedative-hypnotic medications, are cross-tolerant with alcohol and effectively treat alcohol withdrawal.7 Acute alcohol withdrawal in the United States is most often managed with benzodiazepines.

8 There are a variety of benzodiazepines available, from ultra-short-acting to long-acting, as well as parenteral and oral forms. Diazepam has been used extensively due to rapid onset of action when given intravenously and long duration of action when given orally.

For similar reasons, chlordiazepoxide is also used widely. Lorazepam, an intermediate-acting benzodiazepine that can be given orally or parenterally, has been used extensively for treatment of acute alcohol withdrawal, especially in hospitalized patients, because it has fewer active metabolites than other benzodiazepines.

This makes it safer to use in treating patients with severe liver disease, which is important when treating chronic alcoholics. Benzodiazepines have a relatively high therapeutic index when used to treat patients with illnesses in addition to acute withdrawal.

This makes benzodiazepines an excellent choice for the treatment of acute withdrawal in patients on general medical wards.

Barbiturates have been used successfully to treat acute alcohol withdrawal syndrome in general medical inpatients, with phenobarbital the most common choice.9,10 Phenobarbital may be preferable to other sedative-hypnotics; with its longer half-life, patients rarely achieve a “high” as they do with other sedatives, and it is available in multiple dosage forms.11

A number of alternative non-sedative-hypnotic medications exist to treat acute alcohol withdrawal.

Beta-adrenergic blockers (atenolol, propranolol), clonidine, and anticonvulsant agents (carbamazepine, valproate) decrease alcohol withdrawal symptoms and have been used successfully in the treatment of mild withdrawal.

They are not cross-tolerant with alcohol, however, and may result in progression of the withdrawal syndrome. These alternative medications are not appropriate to use as single agents in the treatment of withdrawal in a general medical setting.

Dosing regimens: There are no standard protocols for withdrawal management in widespread use.12 A fixed dosing schedule is commonly used for treatment of acute withdrawal, but either fixed-schedule or symptom-triggered dosing—medication given as needed for withdrawal signs—is efficacious in the treatment of withdrawal, even in patients with medical comorbidity.6

Fixed-schedule dosing is a one-size-fits-all approach for treating alcohol withdrawal. It uses the same dose of cross-tolerant medication on a fixed schedule for all patients for 24-48 hours; the dose is then tapered if the patient is stable. (See Table 2, left.

) Reducing the dose by 10%-20% of the initial dose each day over five to 10 days provides a comfortable taper—especially in patients who initially required higher doses of medication to control the withdrawal.

Fixed-schedule dosing offers less flexibility for individual patients, but it is a simple approach that can be applied in many settings.

Symptom-triggered therapy occurs when cross-tolerant medication is given only for symptoms of withdrawal rather than on a schedule. (See Table 3, p. 25.) Patients are monitored closely and assessed regularly using a tool such as the CIWA-Ar.

The dose of cross-tolerant medication prescribed is the severity of withdrawal symptoms as measured by the CIWA-Ar score. This approach is similar to the sliding scale of insulin dosing used to treat hyperglycemia.

Symptom-triggered therapy provides individualized treatment for withdrawal without overmedicating or underdosing, but it is a complex system to carry out on a general medical unit.

Severe withdrawal: Treat severe DTs manifested by abnormal and fluctuating vital signs and/or delirium aggressively in an ICU environment with sufficiently large doses of medication to suppress the withdrawal.

11 Use IV medications with a rapid onset of action for immediate effect. Lorazepam and diazepam have a rapid onset of action when given intravenously, although the duration of action is shorter than when given orally.

For example, give lorazepam in a dose of one to four mg every 10-30 minutes until the patient is calm but awake and the heart rate is below 120 beats per minute.

A continuous intravenous infusion may be warranted to control withdrawal symptoms, and the rate can be titrated to the desired level of consciousness.

After stabilization, the patient can be changed to an equivalent dose of a long-acting sedative-hypnotic and tapered as above.

Assessing and medicating acute withdrawal remain necessary first steps in the treatment of the disease of alcohol dependence.

After acute detoxification has begun, long-term treatment of alcoholism is necessary to prevent readmission for continuing medical problems due to alcohol consumption.

Refer patients who have been treated for alcohol withdrawal for long-term treatment of alcoholism. This may include Alcoholics Anonymous, outpatient counseling, and other treatment modalities.


Ask all patients admitted to the hospital about drinking alcohol and be alert for signs of acute alcohol withdrawal in any patient. The best predictor of whether a patient will develop acute withdrawal is a past history of withdrawal. Signs of withdrawal usually occur within 48 hours of the last drink. Untreated withdrawal may result in significant morbidity and mortality.

Patients in withdrawal should be monitored closely and given appropriate doses of benzodiazepines or barbiturates to treat withdrawal signs.

Cross-tolerant medication may be given on a fixed schedule or as symptom-triggered therapy. Severe withdrawal may require a continuous intravenous infusion in an ICU.

Recognition and effective treatment of alcohol withdrawal can prevent significant complications in hospitalized patients. TH

Dr. Weaver is associate professor of internal medicine and psychiatry at Virginia Commonwealth University, Richmond.


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Источник: https://www.the-hospitalist.org/hospitalist/article/123281/dealing-dts

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