Delirium Tremens

Question 1

When does it usually occur?

Answer 1

usually 24-72 hours after last drink (or dramatically reduce)

Question 2

Why does it occur when someone suddenly stops drinking alcohol?

Answer 2

As an alcoholic’s body is dependent on alcohol, so their CNS no longer is able to easily adapt to a lack of alcohol

Question 3

How long does delirium tremens usually last?

Answer 3

24 hours to 5 days

Question 4

What percentage of patients with DT die?

Answer 4

5-15%but mortality rate can be up to as high as 35%

Question 5

What are the risk factors of DT?

Answer 5

• Previous history of DT
• Previous seizures with alcohol withdrawal
• Co-existing infection or medical problems e.g. pancreatitis or hepatitis
• Recent alcohol intake that was higher than normal levels
• Older age
• Abnormal liver function
• More severe withdrawal symptoms on presentation

Question 6

What are the common presenting symptoms of DT?

Answer 6

• Extreme confusion with acute onset
• Extreme agitation
• Fever
• Tremors
• Seizures (grand-mal)
• Rapid mood changes
• Tactile hallucinations (sense of itching/burning/numbness)
• Auditory hallucinations
• Visual hallucinations (Lilliputian hallucinations)
• Cardiac arrhythmias
• Fatigue
• Deep sleep lasting more than a day

Question 7

What examination findings may be found with DT?

Answer 7

• Tachycardia
• Hyperthermia and excessive sweating
• HTN
• Tachypnoea
• Tremor
• Mydriasis (dilation of pupil)
• Ataxia
• Altered mental status (reduced GCS, increased agitation or drowsiness)
• Cardiovascular collapse

Question 8

What investigations would be undertaken for DT?

Answer 8

DT is diagnosed clinically and often there is known history of alcohol misuse/dependence
• BLOOD TESTS  help to assess other medical problems and may also show dehydration and electrolyte disturbance
o FBC, LFTs, Clotting, ABG (check for metabolic acidosis), Glucose, Blood alcohol levels, U&Es, creatinine, Amylase, Creatinine phosphokinase, Blood cultures
• CXR  do if signs of respiratory distress
• CT head  if seizures or evidence of recent head injury
• ECG  may show arrhythmia

Question 9

What initial management would be done for DT?

Answer 9

ABCDE

Question 10

What other Mx may be needed?

Answer 10

• Treat any hypoglycaemia
• Sedate with benzodiazepines  Chlodiazepoxide (lorazepam when liver disease)
• Addition of barbiturates may also be needed to reduce need for mechanical ventilation in ITU
• May also have to treat Wernicke’s encephalopathy if also present (IV Pabrinex (500mg thiamine) give three times daily for 3 days)
• Magnesium may be given to protect against seizures and arrhythmias