Reporting About Substance Abuse 2
Reporting About Substance Abuse 2
Reporting About Substance Abuse 2
A rare, life-threatening condition, which is the most severe manifestation of alcohol withdrawal.
Occurs as early as 48 to 72 hours after abrupt cessation of alcohol
Meaning or definition
It is typically in those with a history of chronic alcohol use and those who have previously experienced severe
alcohol withdrawal symptoms, and it doesn’t occur in everyone who withdraws from alcohol. It has an
anticipated mortality of up to 37% without appropriate treatment. It is crucial to identify early signs of
withdrawal because it can become fatal. This activity examines when delirium tremens should be considered
and how to properly evaluate it.
The pathophysiology of delirium tremens (DTs) is complex and not fully understood, but it is thought to involve
a combination of neurochemical, neuroadaptive, and neuroinflammatory processes. DTs typically occur in
individuals with a history of heavy and prolonged alcohol use, and the sudden cessation or significant
reduction in alcohol intake triggers this severe withdrawal syndrome.
Pathophysiology:
Here is an overview of the key factors and processes involved in the pathophysiology of DTs:
Neurochemical Imbalance:
Chronic alcohol abuse affects the balance of various neurotransmitters in the brain, including gamma-
aminobutyric acid (GABA), glutamate, and dopamine. GABA is an inhibitory neurotransmitter that is enhanced
by alcohol, leading to sedation and relaxation. When alcohol is abruptly discontinued, GABA activity decreases,
leading to a state of hyperexcitability in the central nervous system.
Glutamate Excitation:
Glutamate is an excitatory neurotransmitter in the brain. Chronic alcohol use suppresses glutamate
activity to counterbalance the sedative effects of GABA. During alcohol withdrawal, there is an excess release of
glutamate, which contributes to increased neural excitation and the development of symptoms such as anxiety,
restlessness, and seizures.
Neuroadaptive Changes:
Prolonged alcohol exposure leads to neuroadaptive changes in the brain, including upregulation of
certain receptors (e.g., N-methyl-D-aspartate or NMDA receptors) in response to chronic inhibition by alcohol.
When alcohol is abruptly removed, these adaptations result in an increased sensitivity to glutamate, further
exacerbating neural excitation.
Chronic alcohol use can lead to dysfunction of GABA receptors, making them less responsive to GABA
and contributing to hyperexcitability during withdrawal.
Inflammatory Processes:
Alcohol abuse can also lead to systemic inflammation, which can affect the brain's microenvironment.
Inflammatory cytokines may contribute to the development of delirium and other neuropsychiatric symptoms
seen in DTs.
Genetic predisposition and individual variations in neurochemistry may play a role in the susceptibility
to DTs. Some individuals are more prone to severe withdrawal symptoms than others.
In summary, the pathophysiology of delirium tremens involves dysregulation of neurotransmitters,
particularly GABA and glutamate, as well as neuroadaptive changes in response to chronic alcohol exposure.
These factors contribute to the hyperexcitable state of the central nervous system observed during DTs. It is
important to recognize that DTs is a medical emergency, and prompt medical intervention is essential to
manage and mitigate the potentially life-threatening complications associated with this condition.
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Risk Factors
RESCUE DT:
Assessment
General Assessment
brief history regarding the quantity, pattern, duration, and type of alcohol intake
past history of DT or withdrawal seizure
History regarding the use of other substances (Benzodiazepines)
Physical examination
Clinical institute withdrawal assessment scale (CIWA-AR) - the most commonly used instrument is Clinical
Institute Withdrawal Assessment for Alcohol (CIWA-A) scale, particularly the 10 item revised version, known as CIWA-Ar.
Most of the measures in the CIWA-Ar are objective; therefore require minimum patient's cooperation. This is important
to note because patients with DT are usually agitated and less likely to cooperate
Alcohol withdrawal scale (AWS) -Alcohol Withdrawal Scale (AWS) which is an eleven item scale is based entirely on
objective physical or cognitive measures.
Confusion assessment method - Confusion Assessment Methods (CAM) most commonly used screening
instruments of delirium. The instrument assesses features of acute onset, inattention, disorganized thinking and
altered level of consciousness.
Confusion assessment method-ICU - developed for ICU or for nonverbal patients. Delirium is diagnosed
when patients demonstrate: (1) an acute change in mental status or fluctuating changes in mental status; (2)
inattention measured using either an auditory or visual test; and either (3) disorganized thinking; or (4) an
altered level of consciousness.
Clinical:
Looking for Wernicke Encephalopathy: clinically by eye signs, cerebellar signs, altered mental state or
memory problems, signs of dietary deficiency (any two of these four features) - One of the most common
but frequently ignored co-morbidity; WE is reported to be 1.4% (the figure is close to the occurrence of DT) in
hospitalized patients with chronic alcohol use. However, the incidence could rise to 58%, when autopsy samples
are taken from patients with severe alcohol problems.
Laboratory:
ECG
Liver function test
Serum electrolytes
Complete blood count
Acid-Base Balance
Echocardiography
Magnetic Resonance Imaging brain
REFERENCES:
Rahman, A. (2023, August 14). Delirium Tremens. StatPearls - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK482134/
Grover, S., & Ghosh, A. (2018). Delirium Tremens: Assessment and management. Journal of Clinical and Experimental