Delirium Tremens (DTs) Severe Alcohol Withdrawal

What is delirium tremens?

Delirium tremens is a condition of major disruptions in the nervous system associated with severe alcohol withdrawal. In most cases it arises about 72 hours after stopping alcohol consumption but may occur even a week after. Delirium tremens is often associated with the typical image of an agitated person, who is confused, hallucinating, sweating and vomiting profuse and experiencing tremors. The presentation may vary from milder symptoms to a more extreme manifestation. It can lead to complications, some of which can be life threatening without proper management.

How common is delirium tremens?

Delirium tremens (DTs) is not a common occurrence in alcohol withdrawal. In fact, less than 50% of patient who discontinue alcohol consumption experience withdrawal symptoms. Only 5% experience DTs. The most severe manifestation of alcohol withdrawal symptoms is delirium tremens and is more likely to be seen in chronic alcoholism extending for about a 10 year period. However, excessive daily drinking for even a few months can elicit DTs with alcohol withdrawal.

Why do DT’s occur?

Delirium tremens (DTs) are a consequence of chronic alcoholism. With prolonged and excessive use of alcohol, the secretion and functioning of different neurotransmitters in the brain are affected. Neurotransmitters, commonly referred to as brain hormones, are chemical messengers that are released from one nerve cell (neuron) to stimulate or inhibit another nerve cell. These neurotransmitters are in play throughout the day and night. However, its secretion and duration of action needs to be controlled to prevent overactivity of underactivity of the nervous system. The complex interaction between the electrical impulses along the nerves, the neurotransmitters at the nerve endings and the receptors on the other nerves which it acts upon is an integral component of the complexity of the human nervous system.

GABA Receptors

With chronic alcoholism, the naturally occurring quantities and functions of the neurotransmitters are disrupted. One such disruption involves the neurotransmitter GABA (gamma-aminobutyric acid). It is a an inhibitory neurotransmitter meaning that it decreases activity of the nerves to which it binds. Withdrawal affects the receptors to which GABA attaches to in order to function, known as GABA receptors. Therefore the neurotransmitter GABA, although present in normal amounts, cannot function as it should. In addition, the NDMA receptors which are normally blocked with alcohol becomes active again. These nerve receptors when activated cause excitation of nerves. Through these mechanisms, among others, nerve activity is not controlled and there is overactivity of the nervous system.

Signs and Symptoms

Delirium tremens is the most severe manifestation of alcohol withdrawal that arises between 72 hours to 10 days after the last drink. Prior to the onset of delirium tremens, a person may experience other symptoms that can be categorized as :

  • minor withdrawal within 6 to 24 hours after alcohol withdrawal.
  • major withdrawal within 10 to 72 hours after the last drink.
  • withdrawal seizures between 6 to 26 hours after the last drink.

The symptoms in each of these phases differ to some extent and delirium tremens is the most severe presentation. However, it is not uncommon for people to commonly refer to all alcohol withdrawal symptoms in the different categories as delirium tremens.

  • Tremors
  • Agitation, excitement and restlessness
  • Confusion and disorientation
  • Fear and anxiety
  • Extreme sleepiness with deep sleep for long periods, but sometimes sleeplessness
  • Sensitivity of senses to light, sounds and touch
  • Difficulty concentrating and sudden mood changes
  • Severe fatigue
  • Seizures (technically withdrawal seizures)
  • Hallucinations
  • Diminished appetite
  • Paleness
  • Nausea and vomiting
  • Excessive sweating
  • Palpitations
  • Fever in some patients.

It is important to note that the symptoms of DTs can be seen with other acute neurological conditions. The most likely is meningitis and traumatic brain injury.

Causes of Delirium Tremens

Delirium tremens is a result of nervous system overactivity as a result of alcohol withdrawal. The reasons why DTs occur has been explained above but it does not occur in every person who discontinues alcohol consumption. People who have been drinking for more than 10 years are at a greater risk of DTs upon cessation of alcohol. It can occur with just a few months of alcohol consumptions as is seen with people who quit drinking after having consumed 4 to 5 pints of wine (about 2 to 2.5 liters or about three 20 fluid ounce bottles), 7 to 8 pints of beer or just 1 pint of spirits on a daily basis.

Risk factors

Those alcoholics who are more likely to experience delirium tremens, apart from the duration and quantity of alcohol consumption, are those with one or more of the following risk factors.

  • Without proper eating (malnutrition).
  • Experience alcohol withdrawal seizures.
  • History of DTs on previous attempts to discontinue withdrawal.
  • Traumatic head injury.
  • Other illnesses like a concurrent infection during the detox period.
  • Intense alcohol craving.

Some of these risk factors, like withdrawal seizures and an intense craving for alcohol, should serve as warning signals that a person is probably more likely to suffer with delirium tremens. Appropriate measures should therefore be undertaken by seeking advice and treatment from a medical professional or having the person admitted to a medical institution.

Tests and Diagnosis

The symptoms of DTs in a patient with a known history of alcoholism should warrant further investigation. The symptoms may at times not be due to alcohol withdrawal but rather conditions such as meningitis or traumatic head injury, which if left untreated can be fatal. Further testing is not only necessary to exclude other causes of the symptoms but also diagnose underlying conditions which may or may not be associated with chronic alcoholism or alcohol withdrawal. This includes malnutrition, pancreatitis, diabetic ketoacidosis and overdose of illicit drugs or prescription medication.

There are various laboratory tests and imaging studies that should be considered in a patient with delirium tremens, or a patient admitted to hospital with a history of alcoholism for whatever reason.

  • Blood tests :
    – Urea and electrolytes
    – Liver function tests
    – Pancreatic enzymes
    – Blood glucose
    – Alcohol concentration
    – Drug screening
  • Scans :
    – Chest x-rays to evaluate any injury or infections like pneumonia.
    – Head CT scan to note any signs of traumatic head injury or other abnormalities of the brain.
  • Lumbar puncture to rule out meningitis which may present with similar symptoms as DTs.

Treatment for Delirium Tremens

Treatment is aimed at stabilizing a patient, ensuring that complications do not arise or are at least minimized and easing the symptoms of delirium tremens. Supportive measures in a hospital setting is important to ensure that prompt medical treatment is at hand in the event of complications.

  • Patients should be placed in a well lit room with a calming atmosphere.
  • The patient needs to be reassured and the support of family members is helpful.
  • Intravenous (IV) fluids need to be administered with a 5% dextrose solution to prevent hypoglycemia.
  • Thiamine and magnesium supplements need to be administered to correct deficiencies.
  • Constant monitoring for airway obstruction is necessary which can be prevented by placing the patient lying on their left side (lateral left decubitus position) or by intubating the unconscious patient.
  • Other vital signs needs to be monitored on a constant basis.

Medication

  • Anticonvulsants for seizures – phenobarbitol.
  • Benzodiazepines for anxiety, sedation and other withdrawal symptoms – diazepam or lorazepam.
  • Antipsychotics for hallucinations but it can contribute to seizures – haloperidol.

Sedation for a period of one week or more may be advisable until withdrawal is complete. Alcohol, even small amounts, should not be used to treat or prevent delirium tremens.

References :

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001771/

http://emedicine.medscape.com/article/166032-overview

http://www.emedicinehealth.com/script/main/art.asp?articlekey=136906&ref=128256