Definition of Delirium Tremens
Delirium tremens (DT) is a severe, potentially fatal complication of alcohol withdrawal syndrome characterized by the combination of severe alcohol withdrawal symptoms (tremor, sweating, hypertension, tachycardia) together with delirium features (altered mental status, disorientation, hallucinations, and autonomic hyperactivity), typically occurring 3-5 days (approximately 72 hours) after abrupt cessation of chronic alcohol consumption. 1, 2, 3, 4
Core Clinical Features
Delirium tremens represents the most severe spectrum of alcohol withdrawal and includes:
- Altered mental status with disorientation to person, place, or time 1
- Fluctuating consciousness with intra- and inter-daily variations of symptoms 1, 4
- Autonomic hyperactivity including high fever, tachycardia, hypertension, and profuse sweating 1, 4
- Perceptual disturbances such as visual hallucinations and delusions 1, 4
- Severe tremor and agitation (hyperactive delirium subtype) 1, 4
Epidemiology and Timing
- Prevalence is <1% in the general population and approximately 2-5% in patients with alcohol dependence 3, 5
- Symptoms typically peak at 3-5 days (approximately 72 hours) after the last alcohol intake, though onset can occur 6-24 hours after cessation 1, 5
- Without prompt recognition and treatment, mortality can reach 50%, making this a true medical emergency 5, 6
Critical Distinguishing Features from General Delirium
While delirium tremens shares the core features of delirium (acute onset, fluctuating course, inattention, altered consciousness), DT is specifically distinguished by:
- Context of chronic heavy alcohol use followed by abrupt cessation 1, 3
- Prominent autonomic instability (high fever, severe tachycardia, hypertension, diaphoresis) that exceeds typical delirium 1, 4
- Specific timing pattern peaking 3-5 days after last drink 1, 5
- Hyperactive subtype predominance with severe agitation and tremor 1, 4
Associated Complications Requiring Evaluation
Clinicians must carefully evaluate for life-threatening comorbidities including:
- Dehydration and electrolyte imbalances 1
- Renal failure 1
- Head trauma 1
- Infection and sepsis 1, 4
- Gastrointestinal bleeding 1
- Pancreatitis 1
- Liver failure (very common in DT patients) 1, 3
- Malignant arrhythmias 4
- Seizures and subsequent trauma 4
Critical Pitfall
The CIWA (Clinical Institute Withdrawal Assessment for Alcohol) protocol is NOT recommended for diagnosis of alcohol withdrawal syndrome or DT, as high scores can occur in other psychiatric conditions (anxiolytic withdrawal, anxiety disorder) and medical conditions (sepsis, hepatic encephalopathy, severe pain) 1. The diagnosis remains clinical based on the constellation of features described above.