JOURNAL READING

Delirium Tremens

Preceptor:
dr. Iwan Sys, SpKJ

By:
Dwi Prasetyana Rosadi (201510401011001)
Fajaruddin Ma’ruf (201510401011051)

PSYCHIATRY
MEDICAL FACULTY
UNIVERSITY OF MUHAMMADIYAH MALANG
2017
DEFINITION
Delirium tremens is rare and is a diagnosis by exclusion, so
before commencing treatment, screen for other factors
contributing to delirium, in particular:
 subdural haematoma

 head injury

 Wernicke’s encephalopathy

 hepatic encephalopathy

 Hypoxia

 Sepsis

 metabolic disturbances

 intoxication with or withdrawal from other drugs.

 Delirium Tremens

 A severe form of alcohol withdrawal that includes

sudden and severe mental and/or nervous system
changes.
 Risk Factors
 Excessive alcohol abuse over a period of years
 Average >8 years

 Being >40 years old

 Past history of severe alcohol withdrawal symptoms

 Strong alcohol cravings

 Increased number of days since last drink (prior to

hospitalization)
(Burns, 2011)

(Moses, 2012)

Clinical Manifestations
Symptoms most often occur within 48 to 72 hours after the last drink

 Can last 1 week to 1 month

 Mental status changes

 Confusion, disorientation
 Difficulty staying awake, stupor
 Agitation
 Hallucinations
 Seeing/feeling things that are not there (skin crawling)

 Body tremors (shaking)

 Seizures
 Grand mal seizures
 60% of patients; have between 1-6 seizures

 Other symptoms of withdrawal

(NIH, 2011)
 Anxiety, depression, head ache, nausea, sweating, palpitations
 Diagnostics
 BUN and Creatinine
 Can be elevated, normal or low

 Liver Function Test

 All parameters can be elevated

 Toxicology screening
 May indicate other drugs in the system

 Electrolyte Panel
 Metabolic Acidosis

 CT of head
 Likely negative
(Epocrates, 2011.)
 TREATMENT

 Preventive measures.

 Eliminating and correcting somatic complications.

 Adjusting environmental conditions

 Symptomatic and supportive treatment.

 Treatment

 Medical Care
 Prescribe medications for symptoms
 Benzodiazepines: Ativan, Diazepam
 Anticonvulsants: Tegretol
 Thiamine: Vitamin B1
 Magnesium sulfate
 5% dextrose in 0.45%-0.9% NaCl

(Burns, 2011)
(Kneisl & Trigoboff, 2013)
 Clomethiazole
 The GABA-ergic model of alcohol withdrawal and
withdrawal delirium favors benzodiazepines in the
treatment.
 For adequate alleviation of delirious symptoms, four
to six 300 mg clomethiazole capsules.

 Benzodiazepines
 short-acting agents are preferred (e.g. lorazepam,
midazolam and oxazepam).
 Benzodiazepines (especially clonazepam and diazepam)
are also beneficial in epileptic seizure management as
epileptic activity is a frequent complication seen in
alcohol withdrawal and withdrawal delirium (up to 30%).
They are also the drugs of choice in sedative and
hypnotic withdrawal deliria. Common use in anxiolytic
or other indications (60-90 mg of diazepam equivalent a
day).
 Antipsychotics
 Tiapride, an atypical D2/D3 antipsychotic agent, can
be used in uncomplicated alcohol withdrawal
syndrome.
 the doses can 300 to 1800 mg/day - oral and
parenteral.

 Anticonvulsant
 The anticonvulsants of non-benzodiazepine type
carbamazepine and oxcarbazepine with likely GABA-
ergic and NMDA-blocking activity represent other
drugs of possible use.
 Used in doses of 800 mg a day in both fixed and
tapered regimens.
 clinician-rated withdrawal phenomena using fixed or
tapered (over 5-9 days) regimen with 800 mg daily as
an initial dose.
 Complications of
Treatment
 Oversedation

 Respiratory depression **

 Aspiration pneumonitis

 Cardiac arrhythmias **

(NIH, 2011)
 References
 Burns, M. (2011). Medscape reference. Retrieved from
http://emedicine.medscape.com/article/166032-overview

 Epocrates. (2012). Diagnostic Tests. Retrieved from

https://online.epocrates.com/noFrame/showPage.do?method=dis
eases&MonographId=549&ActiveSectionId=34

 Kneisl, C. R., & Trigoboff, E. (2013). Contemporary psychiatric-

mental health nursing. (3rd ed.). Boston, MA: Pearson Education,
Inc.

 Moses, S. (2012). Alcohol withdrawal. Retrieved from

http://www.fpnotebook.com/Psych/CD/AlchlWthdrwl.htm

 NIH (2011). Delirium Tremens dts; alcohol withdrawal- delirium tremens.

Retrieved from
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001771/