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delirium tremens (DT's)
Is a serious, potentially fatal complication of alcohol withdrawal syndrome.
Epidemiology:
- 5% of patients hospitalized for alcohol withdrawal
Clinical manifestations:
1) onset:
a) may begin as early as 1-3 days after EtOH cessation
b) 48-96 hours after last drink
c) peak incidence in 4-5 days
2) gross tremors
3) seizures
4) incontinence
5) frightening visual hallucinations
6) ataxia
7) vestibular dysfunction
8) autonomic lability
a) diaphoresis
b) tachycardia
c) hyperthermia
d) anxiety
e) insomnia
f) mydriasis
9) delirium
a) confusion
b) depression
Laboratory:
1) complete blood count (CBC) with differential
2) serum chemistries
a) chem 7
b) Ca+2, Mg+2
c) liver function tests
d) folate/B12
e) amylase
f) stool guaiac
3) PT/aPTT, INR
4) hepatitis serologies (B & C)
5) urinalysis
6) urine toxicology
7) CSF analysis
Special laboratory:
- electrocardiogram
- electroencephalogram
Radiology:
1) chest X-ray
2) computed tomography (CT) of head
3) upper GI series
Management:
1) transfer to the ICU & sedate +/- mechanical ventilation for combativeness, agitation & confusion not responding to benzodiazepine or antipsychotic [5]
2) vitals every 6 hours
4) low stimulation environment
5) rehydration
6) pharmaceutical agents
a) benzodiazepines
- lorazepam or oxazepam if liver disease [5]
b) haloperidol* for psychosis
7) prognosis
a) generally clear in 12-24 hours
b) 20% mortality without treatment; 1% with appropriate therapy
* Caution: neuroleptics can decrease the threshold for seizures
General
alcohol withdrawal syndrome
References
- Diagnostic History & Physical Examination in Medicine, Chan &
Winkle, Current Clinical Strategies, Laguna Hills, CA 1996
- Mayo-Smith MF, Beecher LH, Fischer TL, Gorelick DA, Guillaume JL,
Hill A, Jara G, Kasser C, Melbourne J; Working Group on the
Management of Alcohol Withdrawal Delirium, Practice Guidelines
Committee, American Society of Addiction Medicine.
Management of alcohol withdrawal delirium. An evidence-based
practice guideline.
Arch Intern Med. 2004 Jul 12;164(13):1405-12.
Erratum in: Arch Intern Med. 2004 Oct 11;164(18):2068.
dosage error in text.
PMID: 15249349
http://archinte.ama-assn.org/cgi/content/abstract/164/13/1405
- Medical Knowledge Self Assessment Program (MKSAP) 14,
American College of Physicians, Philadelphia 2006
- Schuckit MA
Recognition and Management of Withdrawal Delirium (Delirium
Tremens).
N Engl J Med 2014; 371:2109-2113. November 27, 2014
http://www.nejm.org/doi/full/10.1056/NEJMra1407298
- NEJM Knowledge+ Psychiatry