Snapshot A 46-year-old male underwent an emergency operation for a lung laceration from an altercation. Twenty-four hours later, he developed anxiety, tremors, and insomnia. The patient is started on a benzodiazepine taper, thiamine, multivitamin, IV fluids, and dextrose. Introduction Occurs when a chronic alcohol drinker is suddenly restricted from drinking can be initiated by an acute hospital stay assessed with Clinical Institute Withdrawal Assessment for Alcohol (CIWA) Presentation Symptoms early (12-24 hours) autonomic hyperactivity symptoms tremor, tachycardia, hypertension, anxiety, and insomnia mid (24-48 hours) seizures late (48-72 hours) delirium tremens psychotic symptoms and confusion Treatment Pharmacologic thiamine (administer prior to glucose to prevent worsening of or precipitation of Wernicke encephalopathy) glucose folate sedative-hypnotics with taper e.g., clonidine or propranolol lorazepam if seizures present haloperidol if psychosis present Prognosis, Prevention, Complications Delirium tremens is associated with a high mortality Minor Withdrawal Alcoholic Hallucinosis Withdrawal Seizure Delirium Tremens Time Since Last Drink 6 hours 12 - 24 hours 48 hours 48 - 96 hours Symptoms Trembling Irritability Anxiety Headache Tachycardia Insomnia Visual, auditory, and in some cases tactile hallucinations Tonic-clonic seizures Autonomic instability Disorientation Hallucinations Agitation Management Thiamine Folate Multivitamin Dextrose IV Fluids Begin benzodiazepine taper to avoid seizures Benzodiazepine taper Head CT Suspect in patient with unknown history follwed by DT symptoms 2 days later Benzodiazepine taper