Delirium tremens (severe alcohol withdrawal)
Severe alcohol withdrawal with delirium: warning signs, complications and urgent care.
Key points
- Delirium tremens is the most severe form of alcohol withdrawal and can be life‑threatening.
- It typically develops 48–96 hours after abrupt reduction or cessation of heavy alcohol use.
- Delirium plus autonomic hyperactivity (tachycardia, sweating, fever) and seizure risk require urgent inpatient care.
Definition
Delirium tremens (DT) is a severe withdrawal syndrome characterised by fluctuating inattention and disorientation with hallucinations and marked autonomic instability. It reflects profound neuroadaptation to chronic alcohol exposure and sudden loss of inhibitory GABAergic tone with relative excitatory overdrive. DT should be managed in hospital.
Typical timing
Early withdrawal symptoms may begin within 6–24 hours. DT usually represents the peak phase, often on days 2–4, but timing varies with drinking patterns, comorbid illness and prior episodes.
Clinical features
- Delirium: fluctuating attention, disorganised thinking, agitation.
- Hallucinations (often visual), severe anxiety and insomnia.
- Autonomic signs: tachycardia, hypertension, diaphoresis, tremor, fever.
- Complications: seizures, arrhythmias, aspiration, rhabdomyolysis.
Risk factors
Prior DT or withdrawal seizures, very heavy daily consumption, concurrent infection/trauma/surgery, electrolyte abnormalities (especially magnesium and potassium) and liver disease increase risk.
Assessment
DT is diagnosed clinically, but clinicians must also evaluate alternative or additional causes of delirium (infection, head injury, hypoglycaemia, hepatic encephalopathy). Vital signs, ECG and basic laboratory testing are typically required. Severity scores may support monitoring but do not replace clinical judgement.
Treatment
Management is protocol‑based and includes benzodiazepines titrated to symptom control, fluid and electrolyte correction (magnesium, potassium, phosphate), thiamine before glucose when deficiency is possible, and treatment of coexisting illness. Continuous monitoring is often needed to prevent complications.
Practical tables
| Sign | Appearance | Why it matters |
|---|---|---|
| Tremor/diaphoresis | marked tremor, profuse sweating | severity marker |
| Hallucinations | often visual | injury risk |
| Tachycardia/fever | autonomic storm | arrhythmia/hyperthermia risk |
| Seizure | may precede DT | medical emergency |
Related topics
Intoxication & withdrawal • When it is urgent • Treatment & diagnosis