From the Guidelines
Delirium tremens (DTs) symptoms warranting ICU consultation include severe agitation, confusion, hallucinations, seizures, high fever (>101°F), tachycardia (heart rate >110 beats per minute), hypertension, profuse sweating, and marked tremors, as these symptoms are associated with a high risk of morbidity and mortality 1. The symptoms of delirium tremens can be categorized into several key areas, including:
- Disturbed level of consciousness, with a reduced ability to focus, sustain, or shift attention 1
- Changes in cognition, such as memory deficit, disorientation, or language disturbance 1
- Perceptual disturbances, including hallucinations or delusions 1
- Sleep disturbances, abnormal psychomotor activity, and emotional disturbances, such as fear, anxiety, or depression 1 Patients with respiratory distress, significant electrolyte abnormalities (particularly hypokalemia, hypomagnesemia), severe metabolic acidosis, or hemodynamic instability should be immediately transferred to intensive care, as these conditions can rapidly deteriorate and lead to life-threatening complications 1. ICU consultation is also necessary when patients fail to respond to appropriate benzodiazepine therapy, require high doses of sedatives, or show signs of benzodiazepine resistance, as these factors can increase the risk of adverse outcomes 1. The presence of significant comorbidities, such as liver disease, heart failure, or infection, further justifies ICU-level care, as these conditions can increase the risk of complications and worsen outcomes 1. Early ICU involvement is crucial, as delirium tremens carries a mortality rate of 1-4% even with treatment, and prompt recognition and aggressive management of these symptoms can help prevent life-threatening complications 1.
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
- Symptoms and signs of delirium tremens that may warrant an ICU consult include:
From the Research
Symptoms and Signs of Delirium Tremens
- Delirium Tremens (DT) presents with a combination of severe alcohol withdrawal symptoms and symptoms of delirium with agitation and sometimes hallucination 4
- DT is characterized by an acute confusional state, which is a manifestation of acute encephalopathy 5
- Symptoms of DT include severe alcohol withdrawal symptoms, delirium, agitation, and hallucination 4
Warranting ICU Consult
- DT falls in the most severe spectrum of alcohol withdrawal, which could potentially result in death, unless managed promptly and adequately 4
- The management of DT involves ensuring patient safety and alleviating symptoms, primarily through pharmacological approaches, such as benzodiazepines 6
- Patients with DT may require ICU consultation due to the potential for severe complications, such as autonomic dysregulation, electrolyte imbalances, and coexisting medical conditions 4, 6
- Benzodiazepines, such as diazepam and lorazepam, are the mainstay of treatment for DT, and ICU consultation may be necessary to manage refractory cases or to monitor patients with severe symptoms 4
Clinical Parameters and Treatment
- Clinical and laboratory parameters, such as assessment of severity of alcohol withdrawal, evaluation of delirium, and screening for underlying medical co-morbidities, are crucial in predicting and managing DT 4
- Liver disease is a common co-morbidity in patients with DT, which can complicate the clinical presentation, determine the treatment choice, and influence the outcome 4
- The use of benzodiazepines in the treatment of delirium is controversial, and current guidelines do not recommend their use for this indication, except in cases of alcohol withdrawal-related delirium 7, 8