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| __NOTOC__ | | __NOTOC__ |
| | {{Template:Delirium tremens}} |
| '''For patient information, click [[Delirium tremens (patient information)|here]]''' | | '''For patient information, click [[Delirium tremens (patient information)|here]]''' |
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| {{Infobox_Disease |
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| Name = {{PAGENAME}} |
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| Image = |
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| Caption = |
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| DiseasesDB = 3543 |
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| ICD10 = F10.4 |
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| ICD9 = {{ICD9|291.0}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 000766 |
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| MeshID = D000430 |
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| }}
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| {{SI}}
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| {{CMG}} | | {{CMG}} |
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| {{SK}} the horrors; rum fits; the shakes; shaking delirium; trembling madness; DT's | | {{SK}} Rum fits; DT's; shaking delirium; trembling madness; delerium tremens |
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| ==Overview== | | ==[[Delirium tremens overview|Overview]]== |
| '''Delirium tremens''' is an acute episode of [[delirium]] that is usually caused by [[withdrawal]] or [[abstinence]], from [[alcohol]] following [[alcoholism|habitual excessive drinking]], or [[benzodiazepines]] or [[barbiturates]] (and other major tranquilizers).
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| ==Pathophysiology== | | ==[[Delirium tremens historical perspective|Historical Perspective]]== |
| Delirium tremens can also appear after a rapid reduction in the amount of [[alcohol]] being consumed by heavy drinkers, or a [[benzodiazepine withdrawal syndrome|rapid reduction of intake of benzodiazepines]] or [[barbiturates]]. Caused by alcohol, it only occurs in individuals with a history of constant, long-term alcohol consumption. Occurrence due to [[benzodiazepine withdrawal syndrome|benzodiazepine]] or barbiturate withdrawal does not require as long a period of consistent intake of such drugs. Prior use of both tranquilizers and alcohol can compound the symptoms, and while extremely rare, is the most dangerous especially if untreated. Barbiturates are generally accepted as being extremely dangerous, both due to overdose potential and addiction potential including the extreme withdrawal syndrome that usually is marked by delirium tremens upon discontinuation. | |
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| The exact pharmacology of ethanol is not fully understood: however, it is theorized that delirium tremens is caused by the effect of alcohol on the benzodiazepine-GABA<sub>A</sub>-chloride receptor complex for the inhibitory neurotransmitter [[Gamma-aminobutyric acid|GABA]]. Constant consumption of [[alcoholic beverage]]s (and the consequent chronic sedation) causes a counterregulatory response in the brain in attempt to re-achieve [[homeostasis]]. This causes [[downregulation]] of these [[Receptor (biochemistry)|receptor]]s, as well as an up-regulation in the production of excitatory [[neurotransmitters]] such as norepinephrine, dopamine, epinephrine, and serotonin - all of which further the drinker's tolerance to alcohol and may intensify tonic-clonic seizures. When alcohol is no longer consumed, these down-regulated GABA<sub>A</sub> receptor complexes are so insensitive to GABA that the typical amount of GABA produced has little effect; compounded with the fact that GABA normally inhibits [[action potential]] formation, there are not as many receptors for GABA to bind to - meaning that [[sympathetic nervous system|sympathetic]] activation is unopposed. This is also known as an "[[adrenergic]] storm".
| | ==[[Delirium tremens classification|Classification]]== |
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| This is all made worse by [[excitatory neurotransmitter]] upregulation, so not only is sympathetic nervous system over-activity unopposed by GABA, there is also more of the [[serotonin]], [[norepinephrine]], [[dopamine]], [[epinephrine]], and particularly [[glutamate]]. Excitory [[NMDA receptor]]s are also upregulated, contributing to the [[delirium]] and neurotoxicity (by [[excitotoxicity]]) of withdrawal. Direct measurements of central [[norepinephrine]] and its metabolites is in direct correlation to the severity of the [[alcohol withdrawal]] syndrome.
| | ==[[Delirium tremens pathophysiology|Pathophysiology]]== |
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| ==Causes== | | ==[[Delirium tremens causes|Causes]]== |
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| * [[Alcohol withdrawal]]
| | ==[[Delirium tremens differential diagnosis|Differentiating Delirium Tremens from other Diseases]]== |
| * [[Benzodiazepine withdrawal ]]
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| * [[Barbiturate withdrawal]]
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| ==Differentiating Delirium Tremens from other Disease== | | ==[[Delirium tremens epidemiology and demographics|Epidemiology and Demographics]]== |
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| Delirium tremens (DT) should be distinguished from [[alcoholic hallucinosis]], the latter occurring in approximately 20% of hospitalized alcoholics and not carrying a significant mortality. In contrast, DT occurs in 5-10% of alcohol-dependent people and carries up to 5% mortality with treatment and up to 35% mortality without treatment. DT is characterized by the presence of altered [[sensorium]]; that is, a complete hallucination without any recognition of the real world. DT has extreme [[Autonomic nervous system|autonomic]] hyperactivity (high pulse, blood pressure, and rate of breathing), and 35-60% of patients have a fever. Some individuals experience [[seizure]]s as well.. | | ==[[Delirium tremens risk factors|Risk Factors]]== |
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| ==Epidemiology and Demographics== | | ==[[Delirium tremens screening|Screening]]== |
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| Five percent of acute ethanol withdrawal cases progress to delirium tremens. Unlike the withdrawal syndrome associated with [[opiate addiction]] (generally), delirium tremens (and alcohol withdrawal in general) can be fatal. Mortality can be up to 35% if untreated; if treated early, death rates range from 5-15%.
| | ==[[Delirium tremens natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ==Risk Factors==
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| * [[Head injury]]
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| * [[CNS infection ]]
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| * [[Sepsis]]
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| * [[Drug abuse]]
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| * [[Malnutrition]]
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| * [[Alcoholism]] that has existed for more than 10 years
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| ==Screening==
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| * Screening tools include the '''Alcohol Use Disorders Identification Test''' (AUDIT), AUDIT-C, and the '''CAGE''' screening test
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| ==Natural History, Complications and Prognosis==
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| ===Complications===
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| [[Adrenergic]] storm causes a few complications which include (but are not limited to)
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| * [[Hypertension]]
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| * [[Hyperthermia]]
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| * [[Myocardial infarction|Heart attack]]
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| * [[Cardiac arrhythmia]]
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| * [[Stroke]]
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| ==Diagnosis== | | ==Diagnosis== |
| ===Symptoms===
| | [[Delirium tremens history and symptoms|History and Symptoms]] | [[Delirium tremens physical examination|Physical Examination]] | [[Delirium tremens laboratory findings|Laboratory Findings]] | [[Delirium tremens electrocardiogram|Electrocardiogram]] | [[Delirium tremens chest x ray|Chest X Ray]] | [[Delirium tremens CT|CT]] | [[Delirium tremens MRI|MRI]] | [[Delirium tremens other imaging findings|Other Imaging Findings]] | [[Delirium tremens other diagnostic studies|Other Diagnostic Studies]] |
| The main symptoms are
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| * [[Confusion]]
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| * [[Disorientation]]
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| * [[Agitation]]
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| Other common symptoms include
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| * Intense [[hallucination]]s - [[formication]]
| | [[Delirium tremens medical therapy|Medical Therapy]] | [[Delirium tremens primary prevention|Primary Prevention]] | [[Delirium tremens secondary prevention|Secondary Prevention]] | [[Delirium tremens cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Delirium tremens future or investigational therapies|Future or Investigational Therapies]] |
| * [[Tremor]]s
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| * [[Anxiety]]
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| * [[Panic attacks]]
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| * [[Paranoia]]
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| ===Physical Examination===
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| ====Appearance of the Patient====
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| [[Diaphoresis]], severe psychomotor agitation | |
| ====Vital Signs====
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| * [[Temperature]] - [[Hyperthermia]]
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| * [[Pulse]] - [[Tachycardia]]
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| * [[Blood pressure]] - [[Hypertension]]
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| * Respiratory rate - [[Tachypnea]]
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| ====Neurologic====
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| * [[Tremor]]
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| * [[Altered mental status]]
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| * [[Global confusion]]
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| * [[Disorientation]]
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| ====Eye====
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| * [[Mydriasis]]
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| * [[Positional nystagmus]]
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| === Laboratory Findings ===
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| ==== Electrolyte and Biomarker Studies ====
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| * [[Complete blood count]], [[differential count]]
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| * Drug screening
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| * Blood [[lactate]] levels
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| * [[Osmolal gap]]
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| * Serum levels of following electrolytes
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| ** Sodium
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| ** Potassium
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| ** Chloride
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| ** Bicarbonate
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| ** Blood urea nitrogen (BUN)
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| ** Creatinine
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| ** Magnesium
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| ** Phosphorous
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| ** Liver function tests
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| ** Creatine phosphokinase - Some patients develop rhabdomyolysis
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| ** Lipase
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| ** Ketones
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| * [[CSF]] examination
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| ====Electrocardiogram====
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| * To evaluate any electrolyte abnormalities causing electro physiological changes in heart muscle.
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| ====Chest X Ray ====
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| * To evaluate any associated chest infections.
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| * X rays to evaluate any cervical spinal trauma .
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| ====CT Scan====
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| * CT scan head to evaluate any intra cranial pathology.
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| ==Treatment== | | ==Case Studies== |
| Pharmacotherapy is symptomatic and supportive. Typically the patient is kept sedated with [[benzodiazepine]]s, such as [[diazepam]] (Valium), [[lorazepam]] (Ativan) or [[oxazepam]] (Serax) and in extreme cases low-levels of antipsychotics, such as [[haloperidol]] until symptoms subside. [[Acamprosate]] is often used to augment treatment, and is then carried on into long term use to reduce the risk of relapse. If [[status epilepticus]] is present, [[seizure]]s are treated accordingly.
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| Controlling environmental stimuli can also be helpful, such as a well-lit but relaxing environment to minimise visual misinterpretations such as the visual hallucinations mentioned above.
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| ==References==
| | [[Delirium tremens case study one|Case #1]] |
| {{reflist|2}}
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| ==See also== | | ==Related Chapters== |
| * [[Alcoholism]] | | * [[Alcoholism]] |
| * [[Withdrawal]] | | * [[Withdrawal]] |
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| {{Mental and behavioural disorders}} | | {{Mental and behavioural disorders}} |
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| [[da:Delirium tremens]] | | [[Category:Substance abuse]] |
| [[de:Delirium tremens]] | | [[Category:Alcohol abuse]] |
| [[et:Delirium tremens]]
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| [[es:Delirium tremens]]
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| [[fr:Delirium tremens]]
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| [[hu:Delirium tremens]]
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| [[nl:Delirium tremens (ontwenningsverschijnsel)]]
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| [[nn:Delirium tremens]]
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| [[pl:Majaczenie alkoholowe]]
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| [[pt:Delirium tremens]]
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| [[ru:Белая горячка]]
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| [[sl:Alkoholni delirij]]
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| [[sr:Делиријум тременс]]
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| [[fi:Delirium tremens]]
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| [[sv:Delirium tremens]]
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| [[tr:Deliriyum tremens]]
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| [[Category:Abuse]] | | [[Category:Abuse]] |
| [[Category:Psychiatry]] | | [[Category:Psychiatry]] |
| [[Category:Neurology]] | | [[Category:Neurology]] |
| | [[Category:Disease]] |
| | [[Category:Intensive care medicine]] |
| | [[Category:Emergency medicine]] |
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| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |