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Delirium Tremens: Causes, Symptoms, and Treatment

Medically Reviewed By: Benjamin Caleb Williams RN, BA, CEN

Written By: Phillippe Greenough

Article Updated: 09/14/2020

Number of References: 2 Sources

Delirium tremens, also referred to as alcohol withdrawal delirium, is an extremely intense form of withdrawal which greatly increases the risk of death. Here we will examine causes, contributing factors, and symptoms. With medical help the danger may be minimized as there are a variety of delirium tremens treatments available today.

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What Is Delirium Tremens?

Delirium tremens is a very dangerous condition that is unique to, and caused solely by, withdrawal from alcohol. Commonly abbreviated DTs, this condition is a unique condition that is distinct from the regular symptoms of alcohol withdrawal. DTs introduces additional risks and complications and may last much longer than standard acute withdrawal symptoms. DTs are a catastrophic disruption of normal brain function and perceptions which also affects vital systems such as heart rate, blood pressure, and temperature regulation. This can cause a wide variety of dangerous issues and some of the greatest risks can result in brain damage, seizure, heart attack, stroke, and sometimes death.

DTs manifest symptoms that are distinct from other more minor symptoms of withdrawal. While alcohol withdrawal hallucinations may be experienced before this condition occurs, the hallucinations and confusion during DTs are independent of other minor forms that may present earlier in the withdrawal process.

What Causes Delirium Tremens?

Being a condition unique to alcohol withdrawal, it is necessary to drink heavily for an extended time to develop DTs. The imbalances caused by prolonged alcohol use are responsible for the occurrence of DTs, although it is currently unclear as to the exact mechanisms which produce it. There is also still some mystery as to why DTs occur in some people, and not in others. Out of all people who will experience withdrawal from alcohol, only about 1-5% of them will experience DTs.

There are contributing factors that seem to be common among those who do experience DTs which increase the likelihood of someone experiencing this dangerous condition. Some of these include:

  • The number of previous alcohol withdrawal episodes
  • Past experience of alcohol withdrawal seizures
  • Electrolyte imbalances such as low potassium
  • Current illness such as urinary tract infection or pneumonia
  • Past experience of suffering DTs
  • Age at time of onset
  • The severity of alcohol withdrawal symptoms (more severe symptoms produce a higher chance of developing DTs)

Symptoms of Delirium Tremens

The typical time of onset for DTs is between 48 to 72 hours after someone has had their last drink, although it is possible to occur sooner or later. They have usually been experiencing withdrawal for many hours before DTs present. It may exhibit symptoms similar to withdrawal itself, although during DTs these symptoms are greatly magnified.

Some of the common symptoms of delirium tremens include:

  • Severe Confusion and Disorientation (Delirium)
  • Intense Tremor or Convulsions
  • Elevated Blood Pressure (Hypertension)
  • Very Fast Heart Rate (Tachycardia)
  • Elevated Body Temperature (Hyperthermia or Hyperpyrexia)
  • Excessive Sweating (Diaphoresis)
  • Hallucinations (visual, auditory, tactile, or a combination)
  • Increased Anxiety or Irritability
  • Increased Likelihood of Seizure
  • Dehydration
  • Nausea, Dry Heaving, or Vomiting

These symptoms typically last between 2-3 days after they begin but have been known to linger for 2 weeks in some cases. Many of these symptoms pose a serious risk to someone’s health or even their life.

Alcohol Withdrawal Seizures

Dangers of Delirium Tremens

DTs is a very dangerous condition with a mortality rate of between 2-15%. This was much higher (37%) in the ’70s before effective treatment options and medications for alcohol withdrawal were widely available. Some of the greatest risks are due to heart problems, as the wild fluctuations in blood pressure and heart rate wreak havoc in the cardiovascular system. Likewise, due to blood pressure fluctuations, the risk of stroke is greatly increased.

A list of some of the greatest and most common dangers which can result in death include:

  • Cardiac Arrest (usually due to arrhythmia)
  • Stroke (due to blood pressure fluctuations)
  • Respiratory Failure
  • Aspiration Pneumonitis (due to inhaling stomach contents)
  • Seizures (which may progress to Status Epilepticus)
  • Brain Damage (either from SE seizures or hyperthermia)

Refractory Delirium Tremens

Refractory is a medical term that simply means that a condition is not responding to the normal treatments. This can unfortunately occur with DTs as well as less-lethal conditions such as depression. In cases of refractory DTs, the symptoms have been documented to last as long as 28 days. This is not only extremely unpleasant for the patient but this also increases the risk of dangerous complications as the time of greatest risk is prolonged over several weeks.

Kindling Process

This is a very dangerous condition and while the exact mechanisms are unknown, it is known that experiencing DTs will increase the risk of another episode during subsequent periods of withdrawal. The reasons for this are not fully known, but it probably involves excitotoxicity and sensitization processes that occur in the brain in the time before and after episodes of DTs. Additionally, suffering withdrawal seizures increases the risk of developing DTs through similarly unknown means, but probably through a similar sensitization mechanism.

Delirium Tremens Treatments

DTs is extremely dangerous and in western medicine, it is deemed a “medical emergency” by healthcare workers. The mortality rate of DTs, when left untreated, is a staggering 37% which should illustrate just how lethal a condition it is. With medical supervision, however, this number can be greatly reduced. There have been many effective treatments developed in the last few decades which greatly reduce the dangers. Studies vary, but the current mortality rate is somewhere between 1.8-15%. This most likely tends toward the lower end (1-4%) of the scale, but further definitive studies are needed to hone in on a more precise number.

Entering an alcohol detox center will give someone the best chance of making it through withdrawal in the safest way possible. The most effective way to avoid DTs is to seek medical monitoring and treatment before withdrawal sets in. This way, someone will not only be much more comfortable, but the chances of developing DTs will be greatly reduced through medications, supplements, and supervision.

Medications

The first-line treatment for DTs is a combination of medication, medical monitoring, and nutritional supplements, either oral or intravenous. This comprehensive approach aims to correct the chemical imbalances which result from it. This can prevent it from emerging if treatment is provided beforehand, or reduce the severity and risks once the symptoms are already present.

Some of the medications which are most effective for delirium tremens treatments include:

  • Benzodiazepines (Benzos): Such as lorazepam, diazepam, oxazepam, and more rarely the less potent chlordiazepoxide. These medications directly counteract some of the neurotransmitter imbalances which result in alcohol withdrawal seizures and DTs. This not only reduces the danger but also makes the subjective experience of the symptoms much more bearable.
  • Antipsychotics: Typically haloperidol, this may be used in addition to benzos to help manage the delirium and reduce agitation in general.
    Blood Pressure Medications: Typically beta-blockers such as propranolol or clonidine, these medications may help reduce blood pressure fluctuations. This, in turn, will reduce discomfort as well as lower the risk of a stroke.
  • Barbiturates: This class of medications has been supplanted by benzos today, however, they may still be effective under certain circumstances. In cases where benzos are unavailable or DTs are refractory to benzos, medications such as phenobarbital or pentobarbital may be used.
  • Anesthetics: Medications such as propofol may be used in extreme and/or refractory cases of DTs. This is typically a last resort, as these medications may treat the seizures themselves, but not the underlying causes of these seizures.
Benzodiazepines For Alcohol Withdrawal

Supplemental Therapies

In addition to medications, there are other treatment measures that may be used to help speed up the regenerative processes of the body and mind. This will not only reduce the duration and intensity of the symptoms of DTs, but may also reduce the risk of seizure, brain damage, and stroke.

Some of these common supplemental therapies given either orally or intravenously include:

  • Dextrose: A sugar which will increase blood glucose levels and assist in nutrient absorption and caloric intake.
  • Thiamine: Also known as vitamin B1, alcoholics are commonly deficient in this crucial vitamin. Low levels can lead to a variety of neurological and physical issues such as brain damage and a serious condition known as Wernicke-Korsakoff’s Syndrome.
  • Folic Acid: Also known as folate and vitamin B9, folic acid is critical in the formation of healthy red blood cells. Deficiencies may lead to fatigue and irritability.
  • Magnesium: Used in the form of magnesium sulfate, this mineral is very important in nerve signaling in the brain, and reduced levels can increase the likelihood of experiencing a seizure. Adding magnesium may also reduce the severity and duration of alcohol withdrawal symptoms in general.

Delirium tremens treatments are available and will greatly improve someone’s quality of life and chances for survival. Hospitals, medical detox centers, or inpatient care facilities are highly recommended if someone is experiencing alcohol withdrawal. This is of special importance if someone has suffered alcohol withdrawal previously, and even more so if they have experienced DTs or alcohol withdrawal seizures in the past.

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