Alcoholic delirium tremens

Introduction

Alcoholic delirium tremens is the most dramatic withdrawal syndrome. It usually starts 2-3 days after drinking stops.
On average, the syndrome lasts 3 days but may continue for much longer.
Without good supportive care and adequate treatment, Delirium Tremens (DT) is associated with significant mortality.
Risk factors include long history of heavy alcohol use, previous history of DT, concurrent illness, significant alcohol level during withdrawal, long duration since last drink (over 48 hours) and age over 30 years.

Causes of alcoholic delirium tremens

  • Alcoholic delirium tremens is caused by sudden withdrawal of alcohol from a long-term chronic user of alcohol

Symptoms of alcoholic delirium tremens

The following are the symptoms of alcoholic delirium tremens

  1. Restlessness
  2. Shaking of hands, whole limbs or body
  3. Sweating
  4. Confusion
  5. Inappropriate behaviour
  6. Unintelligible speech
  7. Misidentification
  8. Seeing or talking to imaginary objects

Signs of alcoholic delirium tremens

The signs of alcoholic delirium tremens include the following

  1. Tremors
  2. Psychomotor agitation or retardation
  3. Sweating
  4. Vomiting
  5. Disorientation
  6. Intermittent visual, tactile or auditory hallucinations or illusions (Visual hallucinations are frequently of small objects or frightening ‘animals’ on walls etc.)
  7. Fever > 38°C.
  8. Pulse 100 beats/minute,
  9. Blood Pressure > 160/100mmHg

Investigations

  • Full Blood Count
  • Liver Function Tests
  • Screen for malaria and common infections

Treatment for alcoholic delirium tremens

Treatment objectives

The treatment objectives of alcoholic delirium tremens include the following

  1. To relieve agitation and calm patient
  2. To correct fluid and electrolyte imbalance
  3. To prevent complications like seizures, development of amnesia and encephalopathy
  4. To prevent or manage heart complications if present

Non-pharmacological treatment

  1. Seclusion of the patient
  2. Application of restraints as necessary
  3. Psychotherapy & psychoeducation

Pharmacological treatment

Evidence Rating: [A]

A. For control of seizures

Lorazepam, IV, IM or oral,
Adults

  • Days 1 to 3: 1-2 mg once daily
  • Days 4 and 5: 2-4 mg once daily

Or 40

Diazepam, IV,

(administer slowly-over 2-3 minutes, approximately 2.5 mg every 30 seconds)

Adults

  • Day 1: 10-20 mg 6 hourly
  • Day 2: 10-20 mg 8 hourly
  • Day 3: 10-20 mg 12 hourly
  • Day 4: 5-10 mg 8 hourly
  • Day 5: 5-10 mg 12 hourly then stop

Note

It is best to give benzodiazepines as needed rather on a fixed schedule.
Withhold if patient is asleep or has slurred speech, ataxia, nystagmus or over sedated.

Or

Chlordiazepoxide, oral,
Adults: 50-100 mg 4 hourly as required (max. 300 mg)

And

Thiamine, oral, IM or IV,
Adults (oral, IM, IV): 100 mg daily for 3 days (before any IV Glucose load)

And

Folic Acid, oral,
Adults: 1 mg daily as needed

And

Dextrose saline (5% glucose in 0.9% saline), IV,
Adults: As necessary

B. For patients with seizures not controlled by benzodiazepines alone

Lorazepam, IV, IM or oral, 
Adults:

  • Days 1 to 3: 2-4 mg once daily
  • Days 4 and 5: 1-2 mg once daily

Or

Diazepam, IV,

(administer slowly-over 2-3 minutes, approximately 2.5 mg every 30 seconds)

Adults

  • Day 1: 10-20 mg 6 hourly
  • Day 2: 10-20 mg 8 hourly
  • Day 3: 10-20 mg 12 hourly
  • Day 4: 5-10 mg 8 hourly
  • Day 5: 5-10 mg 12 hourly then stop

And

Phenobarbitone, slow IV or IM,
Adults: 0.5-1.5 mg/kg 12 hourly

Referral Criteria

Refer patients whose symptoms are difficult to control within 3 days or who remain agitated despite being given over 20 mg diazepam within 4 hours to a specialist.
Refer patients to a psychiatrist or clinical psychologist for consideration of other treatment options to assist long-term abstinence and rehabilitation after acute phase is over.