Delirium Tremens (DTs): Alcohol Withdrawal Emergency

Delirium tremens (DTs) is the most severe manifestation of alcohol withdrawal, typically onset 48–96 hours after last drink in chronic heavy drinkers. It is a medical emergency with up to 5% mortality if untreated.

Diagnostic Criteria (DSM-5 / Clinical)

• Alcohol cessation/reduction after prolonged heavy use.
• Acute onset (hours–days) of:

• Altered consciousness (fluctuating attention, disorientation)
• Hallucinations (visual, tactile, auditory)
• Tremor (coarse, intention)
• Autonomic hyperactivity: tachycardia, hypertension, hyperthermia, diaphoresis
• Agitation, delirium

Pathophysiology

Chronic alcohol ↑ GABAergic inhibition & ↓ NMDA glutamate excitation. Abrupt cessation → unopposed glutamatergic surge + GABA downregulation → neuronal hyperexcitability.

Immediate Management (ICU/Monitored Setting)

1. Benzodiazepines (first-line): Lorazepam 1–4 mg IV q5–15 min until sedated (RASS -1 to 0); then scheduled + PRN. Diazepam loading (10–20 mg IV q10 min) alternative. High doses often needed (100s mg diazepam equivalents).
2. Adjuncts for refractory DTs: Phenobarbital 130–260 mg IV, propofol infusion, dexmedetomidine.
3. Thiamine 500 mg IV q8h × 3 days before glucose (prevents Wernicke-Korsakoff).
4. Fluids/electrolytes: Correct dehydration, hypokalemia, hypomagnesemia, hypophosphatemia.
5. Monitor: CIWA-Ar q1–2h, vitals, cardiac rhythm, glucose.

Complications

• Seizures (withdrawal seizures may precede DTs)
• Rhabdomyolysis, aspiration pneumonia, arrhythmias, DIC

Prevention

• Screen for AUD (AUDIT-C) in primary care.
• Medically supervised detox for high-risk patients (history DTs, seizures, comorbidities).
• Outpatient taper with benzodiazepines + thiamine for mild-moderate withdrawal.

DTs is preventable with early recognition and aggressive benzodiazepine dosing. Never "wait it out" at home.