Alcohol Withdrawal Delirium

Alcohol Withdrawal Delirium (Delirium Tremens, DTs) – Treatment Options

Introduction
Alcohol withdrawal delirium, also called delirium tremens (DTs), is the most severe manifestation of alcohol withdrawal. It usually occurs 48–96 hours after the last drink in individuals with heavy, prolonged alcohol use. Clinical features include confusion, disorientation, severe agitation, hallucinations, autonomic hyperactivity (tachycardia, hypertension, fever, diaphoresis), and seizures. DTs carry a high mortality rate if untreated, mainly from cardiovascular collapse, arrhythmias, or infections. Management requires emergency hospitalization, rapid stabilization, and intensive monitoring.

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1. Immediate Stabilization (ABCs)

• Airway protection and oxygenation in severely agitated or obtunded patients.

• IV fluids to correct dehydration and maintain perfusion.

• Electrolyte correction: Especially magnesium, potassium, and phosphate, which are often depleted.

• Temperature control for hyperthermia.

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2. Pharmacological Management

• Benzodiazepines (first-line):

  • Diazepam, lorazepam, or chlordiazepoxide given in repeated IV/IM doses until sedation is achieved.

  • Symptom-triggered dosing preferred, guided by CIWA-Ar scale.

  • Lorazepam preferred in patients with liver impairment.

• Adjunctive therapies:

  • Thiamine (100 mg IV before glucose): Prevents Wernicke’s encephalopathy.

  • Multivitamins and folic acid supplementation.

  • Antipsychotics (e.g., haloperidol): May be used in severe agitation or hallucinations but only as adjuncts to benzodiazepines (risk of lowering seizure threshold).

• Resistant cases (benzodiazepine-refractory DTs):

  • Phenobarbital or propofol (ICU setting) may be used.

  • Require close monitoring due to risk of respiratory depression.

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3. Monitoring and Supportive Care

• ICU admission often required for severe DTs.

• Continuous monitoring of vital signs, ECG, oxygen saturation, and mental status.

• Infection screening: Pneumonia, urinary tract infections, and sepsis are common precipitants.

• Nutrition support: High-calorie, high-protein diet when stabilized.

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4. Long-Term Management

• After recovery from DTs, patients should be enrolled in alcohol rehabilitation programs.

• Relapse prevention pharmacotherapy:

  • Naltrexone, acamprosate, or disulfiram, depending on comorbidities and patient motivation.

• Psychosocial interventions: CBT, motivational interviewing, and support groups (AA, community programs).

• Management of comorbidities: Chronic liver disease, pancreatitis, psychiatric disorders.