Delirium Tremens: Symptoms and Treatment
Clinical Presentation
Delirium tremens (DT) is a life-threatening complication of alcohol withdrawal characterized by severe autonomic hyperactivity combined with altered mental status, typically appearing 48-72 hours after alcohol cessation and peaking at days 3-5. 1
Cardinal Symptoms
- Autonomic instability: High fever, tachycardia, hypertension, profuse sweating 2, 1
- Altered consciousness: Confusion, disorientation to person/place/time, fluctuating mental status 2
- Perceptual disturbances: Visual, auditory, or tactile hallucinations (though not required for diagnosis) 2
- Severe tremor: Marked hand tremor beyond typical alcohol withdrawal 2, 1
- Agitation: Hyperactive delirium with potential for aggressive behavior 3, 4
Critical Complications to Monitor
- Seizures, malignant arrhythmias, respiratory arrest 4
- Dehydration and severe electrolyte imbalances (especially magnesium depletion) 1, 4
- Concurrent infections, gastrointestinal bleeding, hepatic encephalopathy 2, 1
Pharmacological Treatment
Intravenous diazepam is the first-line treatment for delirium tremens, with an initial dose of 10 mg IV followed by 5-10 mg every 3-4 hours as needed, as it provides rapid onset, superior seizure protection, and proven mortality reduction. 1, 5
Benzodiazepine Selection
- Diazepam (preferred): Long-acting agent providing self-tapering pharmacokinetics and superior protection against seizures and mortality 2, 1, 5
- Lorazepam (alternative): Switch to 6-12 mg/day in patients with severe hepatic failure, advanced age, recent head trauma, respiratory failure, or obesity 2, 1
- Benzodiazepines are the only medications proven to prevent seizures and reduce mortality from DT 2, 1, 3
Critical Pitfall: Thiamine Administration
Administer thiamine 100-500 mg IV immediately BEFORE any glucose-containing fluids to prevent precipitating acute Wernicke encephalopathy. 1, 6
- Continue thiamine 100-300 mg/day for 2-3 months following resolution of withdrawal 1, 6
- Failure to give thiamine before glucose is a common and potentially catastrophic error 1
Supportive Care Requirements
Intensive Monitoring
- Continuous vital sign monitoring for autonomic instability (mandatory ICU or monitored ward setting) 2, 4
- Frequent assessment for complications: infection, sepsis, metabolic derangements 2, 6
Fluid and Electrolyte Management
- Aggressive fluid replacement with careful attention to magnesium levels, which are commonly depleted in chronic alcohol use 1, 6
- Monitor and correct other electrolyte abnormalities (potassium, phosphate) 1
Adjunctive Pharmacotherapy
Antipsychotics (Limited Role)
- Haloperidol may be added for severe psychotic symptoms or hallucinations causing distress, but must always be combined with benzodiazepines, never used as monotherapy 7
- Antipsychotics do not prevent seizures or reduce mortality and carry risks of QTc prolongation, extrapyramidal symptoms, and lowering seizure threshold 7
Refractory Cases
- For benzodiazepine-refractory DT in ICU settings: phenobarbital, propofol, or dexmedetomidine as adjunctive therapy only 3
- Dexmedetomidine does not prevent seizures or delirium tremens and cannot replace benzodiazepines 6
Post-Acute Management
Psychiatric consultation is mandatory after stabilization for evaluation, ongoing treatment planning, and long-term abstinence strategies. 2, 1, 6
Relapse Prevention
- Consider medications after withdrawal completion: acamprosate, disulfiram, topiramate, or baclofen 2, 1
- Avoid naltrexone in patients with alcoholic liver disease due to hepatotoxicity risk 2, 1
Common Pitfall
- Do not continue benzodiazepines beyond 10-14 days due to abuse potential 1
- Transition to relapse prevention strategies rather than prolonged benzodiazepine therapy 1
Prognostic Factors
High-Risk Features Predicting DT
- Daily heavy alcohol use (>80 g/day for ≥10 years) 6
- Past history of delirium tremens or alcohol withdrawal seizures 8
- Concurrent medical comorbidities, especially liver disease 3, 4