What are the symptoms and signs of delirium tremens (DTs) that warrant an Intensive Care Unit (ICU) consult?

From the Guidelines

Delirium tremens (DT) symptoms warranting ICU consultation include severe agitation, confusion, hallucinations, seizures, autonomic instability with tachycardia (heart rate >110 bpm), hypertension, hyperthermia (temperature >101°F), and profuse sweating, as these symptoms are associated with high morbidity and mortality rates 1. The symptoms of delirium tremens can be complex and varied, but the key features include a disturbed level of consciousness, inattention, and either disorganized thinking or an altered level of consciousness 1. Some of the key symptoms and signs that warrant ICU consultation include:

• Severe agitation and confusion
• Hallucinations and seizures
• Autonomic instability with tachycardia, hypertension, and hyperthermia
• Respiratory distress and significant electrolyte abnormalities
• Hemodynamic instability and uncontrolled hypertension
• Cardiac arrhythmias and high doses of benzodiazepines for symptom control Patients with comorbidities such as coronary artery disease, liver disease, or respiratory conditions may need earlier ICU transfer due to higher risk of complications 1. Treatment typically involves high-dose benzodiazepines, such as diazepam 10-20mg IV or lorazepam 2-4mg IV every 1-2 hours, titrated to control symptoms, with some patients requiring continuous infusions 1. Thiamine (500mg IV three times daily), folate supplementation, and careful fluid and electrolyte management are essential components of treatment, as they can help to reduce the severity of DT and improve patient outcomes 1. The severity of DT relates to excessive sympathetic nervous system activity following alcohol withdrawal, with mortality rates of 1-4% even with appropriate treatment, highlighting the importance of early recognition and aggressive management 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:
  • Severe confusion
  • Agitation
  • Hallucinations
  • Seizures
  • Catatonia
  • Other life-threatening reactions such as suicidality 2
  • Similar symptoms are also mentioned in the label for lorazepam (IV) 3

From the Research

Symptoms and Signs of Delirium Tremens

The symptoms and signs of delirium tremens (DT) include:

• Severe alcohol withdrawal symptoms
• Delirium with agitation
• Hallucination 4
• Autonomic dysregulation associated with DT, which requires closely monitoring vital signs and electrolyte imbalances 5
• A wide range of symptoms, which may appear earlier from the last drink in older adults 6

Warranting ICU Consult

DT is a severe condition that can result in death if not managed promptly and adequately 4. The following factors may warrant an ICU consult:

• Severe symptoms, such as agitation and hallucination
• Autonomic dysregulation associated with DT
• Co-morbidities, such as liver disease, which can complicate the clinical presentation and influence the outcome 4
• Benzodiazepine refractory cases, which may require the use of other medications, such as Phenobarbital, propofol, and dexmedetomidine 4
• Older adults, who are at increased risk for alcohol withdrawal syndrome related complications 6

Assessment and Management

The assessment of DT includes:

• Evaluation of the severity of alcohol withdrawal
• Evaluation of delirium
• Screening for underlying medical co-morbidities 4 The management of DT involves:
• Ensuring patient safety and alleviating symptoms, primarily through pharmacological approaches, such as benzodiazepines 5
• Closely monitoring vital signs and electrolyte imbalances 5
• Using screening and assessment tools, such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised, to guide pharmacological management 6