Delirium Tremens

Case Study: Delirium Tremens (DTs)

Patient: John, 52-year-old Male

Presenting Complaint:

John was brought to the emergency department by his family due to confusion, agitation, and visual hallucinations.

History of Presenting Illness:

• Chronic heavy drinker (≥10 years, daily intake of whiskey).
• Stopped drinking 3 days ago after a brief hospital stay for pneumonia.
• Since then, he has experienced tremors, sweating, and restlessness, which progressed to severe confusion, agitation, and visual hallucinations (seeing insects crawling on the walls).
• He is disoriented to time and place and has fluctuating consciousness.

Examination Findings:

• Vitals: HR 120 bpm, BP 160/95 mmHg, Temp 38.2°C.
• Neurological: Marked tremors, hyperreflexia, agitation.
• Cognitive: Disoriented, impaired attention, hallucinating.

Diagnosis:

John presents with Delirium Tremens (DTs) due to acute alcohol withdrawal.

Management:

1. IV Benzodiazepines (e.g., Lorazepam or Diazepam) to prevent seizures.
2. IV Fluids & Electrolyte Correction (Monitor potassium, magnesium).
3. Thiamine (Vitamin B1) Supplementation to prevent Wernicke’s encephalopathy.
4. Close Monitoring in a high-dependency unit.

John showed gradual improvement over 48 hours with treatment and was referred for long-term alcohol rehabilitation.

Definition

• Delirium Tremens (DTs) is a life-threatening, acute withdrawal syndrome that occurs 2-5 days after sudden alcohol cessation in patients with chronic alcohol dependence.
• Characterised by severe autonomic instability, hallucinations, confusion, agitation, and risk of seizures.

Medical emergency requiring urgent treatment to prevent complications.

Causes & Risk Factors

• Chronic Alcohol Use Enhances GABA Activity → CNS Depression & Adaptive Downregulation of GABA Receptors.
• Alcohol Suppresses NMDA Glutamate Receptors → Upregulation Over Time.
• Alcohol Cessation → GABA Withdrawal (CNS Overexcitation) & Excessive Glutamate Activity (Excitotoxicity, Autonomic Hyperactivity).
• Results in Autonomic Dysfunction, Delirium, Hallucinations, and Risk of Seizures.

Risk Factors for Delirium Tremens

🔹 Patients with prior severe withdrawals are at higher risk of DTs with future alcohol cessation.

Clinical Features

Symptoms & Signs of Delirium Tremens

Mnemonic for Delirium Tremens Symptoms: “DT HITS”

Each letter represents a key symptom category:

• D → Delirium (Fluctuating confusion, disorientation, poor concentration)
• T → Tremors & Agitation (Shaking, violent outbursts, restlessness)
• H → Hallucinations (Visual > Auditory, e.g., seeing insects)
• I → Insomnia & Nightmares (Severe sleep disturbance, disturbing dreams)
• T → Tachycardia & Autonomic Hyperactivity (↑HR, BP, sweating, fever)
• S → Seizures (Generalized tonic-clonic seizures within 48 hours)

Additional Signs (Mnemonic: “HITS”)

• H → Hyperreflexia & Tremors (Fine tremors of hands, tongue)
• I → Instability (Autonomic) (Tachycardia, Hypertension, Sweating)
• T → Temperature (Hyperthermia) (Fever, risk of seizures/rhabdomyolysis)
• S → Speech Disorganization (Delusions, incoherence, pressured speech)

🔹 Quick Recall: “DT HITS hard—delirium, tremors, hallucinations, instability, seizures!”

This mnemonic should make it easier to recall Delirium Tremens symptoms and signs! 🚑

🔹 Delirium Tremens presents with a triad of severe autonomic instability, hallucinations, and fluctuating delirium.

Referral Criteria (NICE Guidelines)

Urgent Referral (Medical Emergency – Requires Admission)

• Severe Agitation or Confusion (Risk of Self-Harm or Violence).
• Hallucinations (Distressing or Impairing Consciousness).
• Seizures or Signs of Impending Seizures.
• Severe Autonomic Dysfunction (Hypertension, Hyperthermia, Tachycardia >120 bpm).
• Wernicke’s Encephalopathy Features (Confusion, Ophthalmoplegia, Ataxia).

🔹 Delirium Tremens is a medical emergency requiring hospital admission for IV benzodiazepine therapy.

Diagnosis & Assessment Tools

Clinical Diagnosis (Based on History & Examination)

Screening & Risk Stratification

Differential Diagnosis

🔹 A high CIWA-Ar score (>15) indicates severe withdrawal requiring intensive management.

Management (NICE Guidelines)

Acute Management (Withdrawal & Delirium Treatment)

🔹 IV benzodiazepines are the cornerstone of DTs treatment; avoid antipsychotics unless severe agitation is present.

Long-Term Alcohol Dependence Management

Psychological & Social Support

• Cognitive Behavioural Therapy (CBT) for Addiction.
• Motivational Interviewing (Enhancing Readiness to Change).
• 12-Step Programmes (Alcoholics Anonymous).
• Harm Reduction Strategies (Supervised Detox, Rehabilitation).

🔹 Post-withdrawal support is crucial to prevent relapse and re-hospitalisation.

Prognosis & Complications

Prognosis

Complications of Delirium Tremens

🔹 DTs is a life-threatening condition requiring rapid intervention.

UKMLA Key Points

• Best first-line treatment for Delirium Tremens: IV Benzodiazepines (Lorazepam or Diazepam).
• Best prevention of Wernicke’s Encephalopathy: IV Thiamine (Pabrinex).
• When to refer urgently: Severe withdrawal, seizures, autonomic instability.

Best psychological therapy for long-term recovery: CBT & Motivational Interviewing.