What occurs when delirium is present in delirium tremens (alcohol withdrawal syndrome)?

From the Guidelines

Delirium in delirium tremens is a medical emergency that requires immediate treatment with benzodiazepines as the first-line therapy, specifically using longer-acting agents like diazepam or chlordiazepoxide, to reduce the risk of seizures, cardiovascular complications, and mortality. According to the most recent and highest quality study 1, delirium is an acute confusional state that is common, morbid, and costly, and its symptoms typically begin suddenly and can often come and go throughout the day. The study also highlights the importance of identifying and determining the underlying pathophysiological mechanisms of delirium, which is particularly challenging due to its fluctuating course and broad phenomenological range.

The treatment of delirium in delirium tremens should follow symptom-triggered protocols, with vital signs monitored closely, and supportive care including IV fluids for hydration, thiamine, folate supplementation, and correction of electrolyte imbalances, particularly magnesium and potassium. Haloperidol may be added for severe agitation or hallucinations, but benzodiazepines remain the primary treatment. The use of benzodiazepines is supported by previous studies 1, which highlight their efficacy in reducing withdrawal symptoms and the risk of seizures and/or delirium tremens.

Key points to consider in the treatment of delirium in delirium tremens include:

• Immediate treatment with benzodiazepines as the first-line therapy
• Use of longer-acting agents like diazepam or chlordiazepoxide
• Symptom-triggered protocols
• Close monitoring of vital signs
• Supportive care including IV fluids, thiamine, folate supplementation, and correction of electrolyte imbalances
• Addition of haloperidol for severe agitation or hallucinations, if necessary

It is essential to note that delirium tremens is a medical emergency with mortality rates of 1-4% even with treatment, and prompt and effective treatment is crucial to reduce the risk of adverse outcomes. The study by 1 emphasizes the importance of delirium mitigation, given its associated poor outcomes and increased costs, and highlights the need for further research to determine the safety and efficacy of using antipsychotics, including haloperidol, to treat delirium in ICU patients.

From the FDA Drug Label

More severe acute withdrawal signs and symptoms, including life-threatening reactions, have included catatonia, convulsions, delirium tremens, depression, hallucinations, mania, psychosis, seizures, and suicidality When delirium is present in delirium tremens (alcohol withdrawal syndrome), it is a severe acute withdrawal sign and symptom that can be life-threatening 2 3.

• Delirium tremens is characterized by confusion, disorientation, and altered mental status.
• The presence of delirium in this context indicates a high-risk situation that requires immediate medical attention.

From the Research

Delirium Tremens Symptoms and Treatment

When delirium is present in delirium tremens (alcohol withdrawal syndrome), it is characterized by:

• Changes in consciousness and cognitive and perceptual impairments that fluctuate during the day 4
• Clouded consciousness, disorientation, disturbed circadian rhythms, thought processes, and sensory disturbances, all of which fluctuate in time 5
• Agitation, hallucination, and severe alcohol withdrawal symptoms 6

Treatment Approaches

Treatment of delirium tremens combines a supportive and symptomatic approach, including:

• General support, such as helping the patient to re-orientate, close monitoring of vital signs, and adequate hydration 4
• Symptomatic treatment for agitation, autonomic instability, and hallucinations, using benzodiazepines as the preferred treatment option 4, 5, 6
• High-dose benzodiazepines, such as diazepam and lorazepam, which are considered the gold standard for treating delirium tremens 5, 6
• Other treatment options, such as phenobarbital, propofol, and dexmedetomidine, may be used in benzodiazepine-refractory cases 6

Importance of Prompt Treatment

Prompt and adequate treatment of delirium tremens is crucial to prevent severe complications, including:

• Malignant arrhythmia, respiratory arrest, sepsis, severe electrolyte disturbance, or prolonged seizures and subsequent trauma 5
• Death, which can occur if delirium tremens is not recognized and treated early 5, 6