Delirium Tremens: A Scary Case Study

Delirium Tremens: A Scary Case Study, And it's All True!!

Delirium Tremens, or DT's, is "the" major concern when withdrawing from Alcohol. It is a life threatening syndrome. There are other threatening concerns during an alcohol withdrawal; such as seizures and falls, but Delirium Tremens is the primary cause of hospitalization and, rarely, death due to alcohol withdrawal. 

What is Delirium Tremens or DT's? 
A definition by Medscape puts it succinctly: 

Delirium tremens (DTs) is the most severe form of ethanol withdrawal manifested by altered mental status (global confusion) and sympathetic overdrive (autonomic hyperactivity), which can progress to cardiovascular collapse. DTs is a medical emergency with a high mortality rate, making early recognition and treatment essential. (http://emedicine.medscape.com/article/166032-overview). 

DT's are primarily characterized by a delirium that includes hallucinations, usually accompanied by an elevated temperature, elevated pulse, and elevated Blood Pressure. Delirium can exist by itself and is a concern but it is not in the same class as Delirium Tremens. Once the DT's begin it is often difficult to arrest. The patient must be hospitalized and an ICU (Intensive Care Unit) admission is necessary. 

DT's: A Scary Case Study: 

John's wife, Barbara called Executive Home Detox, desperate for help. Her husband wanted to stop drinking but he didn't want to go into a hospital. She had called 911 and an ambulance with EMT's responded. She wanted the EMT's to take John to the hospital because he was showing signs of emaciation and wasting away. He hadn't eaten in weeks, and he was often incoherent due to his inebriation. The EMT's refused to take John because he said he didn't want to go. True Story!

Barbara sought EHD's assistance. An EHD nurse went to Barbara and John's residence to do an assessment. John did express a desire to stop drinking however he continued to refuse hospitalization. An alcohol detox was prescribed and the nurse began treating John. 

Signs of Delirium: 

Shortly after the initiation of treatment, John displayed signs of delirium. He was observed talking to someone who was obviously not present to Barbara or the nurse. He was either awake or in a sleep/awake state. His Blood Pressure was elevated and he was literally unable to walk to the bathroom or anywhere else. An aggressive dosing of prescribed benzodiazepine was not curtailing his delirium. 

EMT's Refuse to take John to the Hospital: They don't recognize DT's. 

The nurse, recognizing the signs of DT's requested Barbara call 911 again. Barbara was reluctant. She stated they are not going to do anything. They are going to refuse to take him to the hospital.  She did call 911 and they responded within fifteen minutes. Once on site the EMT's greeted John by name, apparently they had been to the house multiple times. They took his vital signs and then asked John if he wanted to go to the hospital. John replied no. And the EMT's looked to the nurse and said "Sorry, if he doesn't want to go. We can't take him" 

The On-Site Nurse Advocates for John: Demands he be hospitalized. 

Wow, the EMT's refuse to take the patient, obviously in DT's, to the hospital. The nurse on site requests the EMT's note the Delirium Tremens taking place and request the EMT's involuntarily take the patient to the hospital. The EMT's refuse. 

The nurse on site then informs the EMT's he will call 911 immediately when the ambulance is out of the driveway and will continue this cycle until the EMT's take the patient to the hospital. The EMT's, sensing the determination of the nurse, beg John to reconsider, and John does. Great, he is on the way to the hospital emergency department. 

But Wait! Will the Emergency Room know John is in DT's? 

The EMT's get John to the Emergency Department of a highly reputable hospital. Barbara and the nurse breathe a sigh of relief. Barbara accompanies John to the ED treatment room. Approximately an hour later Barbara seeks the nurse who is waiting in the ED waiting room. "They want to discharge John". He is refusing treatment and they say he's just drunk!" This is incredulous!

The nurse accompanies Barbara back to John's room in the ED. He assesses John again just in case there was an amazing flight to health. After about 30 seconds it is obvious John is very psychotic and delirious. The nurse requests to speak with the doctor. The doctor reiterates John is fine. And the nurse informs the physician the patient is in the throes of Delirium Tremens and requires treatment in the Intensive Care Unit. The nurse requests another assessment by the physician with an emphasis on exploring if the patient has the DT's. 

Ashen Faced Physician: 

The ED physician acquiesces, and enters John's room alone. Two minutes late the physician comes out of John's room ashen faced and in a mild panic. She confirms John is in the DT's and he will be admitted immediately to the Intensive Care Unit. 

An ICU Admission for Delirium Tremens

John was admitted to the ICU. He was in the ICU for seven days. He was delirious for five of those days and he remembers nothing leading up to hospitalization or for those five days. 

Lessons Learned: 

The lessons learned from this ordeal is that the medical establishment has a difficult time recognizing the DT's. This is understandable because DT's is rarely seen. It is estimated that less than 1% of patients in alcohol withdrawal will have the DT's. When it is rarely seen, it becomes difficult to "easily" diagnose. An experienced nurse, insistent on the proper treatment and hospitalization of this patient probably saved the life of this patient.