What are the main features of delirium tremens?

Main Features of Delirium Tremens

Delirium tremens (DT) is a severe form of alcohol withdrawal characterized by altered mental status, autonomic hyperactivity, and perceptual disturbances that typically occurs 6-24 hours after abrupt cessation of alcohol in chronic users and represents a medical emergency requiring immediate intervention.

Clinical Presentation

Cardinal Features

• Altered mental status:
  • Clouded consciousness with fluctuating severity 1
  • Disorientation to person, place, or time 1
  • Inattention and inability to focus 1
  • Disorganized thinking and speech 1

Autonomic Hyperactivity

• High fever
• Tachycardia
• Hypertension
• Profuse sweating 1
• Hand tremor

Perceptual Disturbances

• Visual or tactile hallucinations
• Illusions
• Misinterpretations 1

Psychomotor Disturbances

• Agitation
• Restlessness
• Increased startle reaction 1

Temporal Pattern

• Symptoms typically begin 6-24 hours after cessation of alcohol 1
• Peak severity occurs at 3-5 days post-cessation 1
• Symptoms fluctuate throughout the day, often worsening at night 1

Associated Complications

Medical Complications

• Dehydration
• Electrolyte imbalance
• Renal failure
• Infection
• Gastrointestinal bleeding
• Pancreatitis
• Liver failure 1

Life-Threatening Complications

• Malignant arrhythmias
• Respiratory arrest
• Sepsis
• Severe electrolyte disturbances
• Prolonged seizures and trauma 2
• Mortality rate of approximately 8% if untreated 3

Subtypes and Variations

DT typically presents as hyperactive delirium with agitation and autonomic hyperactivity, but may include:

• Hyperactive features: restlessness, agitation, constant movement 1
• Mixed features: fluctuation between hyperactive and hypoactive states 1

Diagnostic Considerations

• DT is a clinical diagnosis based on presentation and history of alcohol use
• Vital sign monitoring is essential for assessment and management 1
• The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) may help evaluate severity but should not be used alone for diagnosis 1
• Screening for underlying medical comorbidities is crucial, as liver disease is common in patients with DT 4

Management Approach

• Benzodiazepines are the mainstay of treatment 4
  • Diazepam and lorazepam are preferred, depending on clinical context 4
  • High or even very high doses may be required in severe cases 5
• For benzodiazepine-refractory cases, consider:
  • Phenobarbital
  • Propofol
  • Dexmedetomidine 4, 6
• Supportive care:
  • Fluid and electrolyte management
  • Frequent monitoring of vital signs
  • Management of comorbidities 2

Common Pitfalls

1. Failure to recognize DT early, leading to delayed treatment and increased mortality
2. Inadequate benzodiazepine dosing (doses may need to be significantly higher than standard)
3. Overlooking underlying medical conditions that may complicate management
4. Insufficient monitoring of vital signs and electrolytes
5. Failure to transfer to ICU when indicated for close monitoring 1, 2

DT is a medical emergency that requires prompt recognition and aggressive treatment to prevent potentially fatal outcomes. The severity of symptoms and high mortality rate necessitate management in an intensive care setting with continuous monitoring.