Alcohol Withdrawal (Delirium Tremens)

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Definition

Acute confusion that occurs within hours to days of stopping or reducing alcohol intake after prolonged (weeks to months) or prolonged heavy consumption. Usually occurs at 24-48 hours after last drink and it can last for 7-10 days if untreated. 

Signs and Symptoms

  • malaise, nausea/vomiting
  • tremors, sweating, shaking
  • increased heart rate and blood pressure
  • agitation, confusion, labile mood
  • insomnia

Severe withdrawal, or ‘delirium tremens’ (‘shaking delirium’), occurs in 5% of withdrawals and has a mortality of up to 15%, partly as a result of other medical complications. Symptoms as above plus some of:

  • confusion
  • marked agitation
  • aggression
  • hallucinations (usually visual)
  • delusions

Delirium Tremens is a medical emergency. Urgent management as an inpatient by the medical team is required.

If not treated appropriately, it can lead to long-term brain damage (Wernicke’s encephalitis and Korsakoff’s syndrome). It is particularly important to always give thiamine to prevent this.

Assessment

Person has recently stopped drinking alcohol and is now showing any of the above symptoms.

Investigations

  • Full physical examination including vital signs (to exclude other causes of delirium)
  • Consider FBC / LFT
  • Blood or urinary glucose

Management of Withdrawal

Aim is to reduce the symptoms associated with alcohol withdrawal which can result in seizures and potentially be fatal.

A short course of Diazepam should be given, initially at least four times a day, reducing in dose over a week, titrated according to symptom resolution, e.g.:

  • Diazepam 20mg oral qid on day 1
  • Diazepam 15mg oral qid on day 2
  • Diazepam 10mg oral qid on day 3
  • Diazepam 5mg oral qid on day 4
  • Diazepam 5mg oral bd on day 5
  • Diazepam 5mg oral nocte on day 6

Caution: Diazepam can cause slowed breathing (respiratory depression) particularly if taken with alcohol.  If possible, arrange for a family member to administer the medication.

Note: The dose of Diazepam should be reduced in the physically fail or those with liver impairment.

Always give Thiamine supplementation also:

  • Thiamine 100mg orally tds for 1 month
  • Thiamine 100mg orally od indefinitely

More severe cases

If markedly agitated and unable to comply with oral medication:

  • Diazepam 5-10mg IM or slow IV injection (max 5mg/minute) up to 4 times per day until able to comply with oral treatment
  • Thiamine 100mg IV/IM
  • IV fluids may be required if evidence of dehydration (low BP, tachycardic). Caution: don’t give glucose/dextrose unless you have already given IM/IV thiamine

Follow-up

  • If agitation is severe, review patient every few hours
  • As an outpatient, review at least every 24-48 hours until stable
  • If admitted, review every 8 hours until stable
  • Once detoxification is complete, offer advice regarding safe levels of alcohol and counselling support if planning to stop drinking

Red Flags

Admit as medical emergency:

  • anybody with delirium tremens
  • people with high risk of seizures (previous seizures, known epilepsy, prolonged heavy alcohol use)
  • people with co-morbid physical illnesses (HIV, jaundice)