Last month, this column highlighted alcohol use in trauma patients, including a smaller group of chronic drinkers. This subgroup was prone to exhibiting alcohol withdrawal symptoms, which, if left untreated, could progress into delirium tremens (DTs).* Delirium tremens is Latin for “shaking frenzy,” a condition also referred to as the horrors, the bottle ache, quart mania, gallon distemper, barrel fever, the shakes, or the fear.†
Alcohol withdrawal presents with a spectrum of symptoms. The most severe alcohol withdrawal symptoms are DTs, which involve sudden and severe mental or nervous system changes and are most common in people with a prior history of alcohol withdrawal. Typically, individuals who are prone to develop DTs have a daily consumption of four to five pints of wine, seven to eight pints of beer, or one pint of hard alcohol for a period of several months. DTs are also seen in those individuals who have had an alcohol habit for longer than 10 years.‡
Symptoms most commonly arise 48–96 hours after the last drink; however, they have been reported to occur as many as seven to 10 days after the last drink. These symptoms quickly get worse and may include body tremors, change in mental function, agitation, confusion, delirium, fear, hallucinations, quick mood changes, restlessness, auditory and visual sensitivity, and stupor.‡ Seizures, when they occur, are most common in the first 12–48 hours after the last drink, are more common in people with past complications from alcohol withdrawal, and are generalized tonic-clonic in nature. (Tonic-clonic seizures are what many people think of when they hear the word “seizure.” An older term for them is “grand mal.” As implied by the name, they combine the characteristics of tonic seizures and clonic seizures.)
DTs and trauma patients
To examine the occurrence of injuries in which DTs occurred, admissions medical records in the National Trauma Data Bank® (NTDB®) research dataset for 2013 were searched using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses codes. Specifically searched were records containing diagnosis Code 291.0, alcohol delirium tremens. A total of 289 records containing a diagnosis of DTs were found; 282 of these records contained a discharge status, including 161 patients discharged to home, 45 to acute care/rehab, and 66 sent to skilled nursing facilities; 10 died. Approximately 88 percent of these patients were male, on average 54.2 years of age, had an average hospital length of stay of 16 days, had an intensive care unit length of stay of 8.8 days, had an average injury severity score of 11.9, and were on a ventilator for an average of 8.8 days. This group of DT patients had a similar ISS to the alcohol withdrawal patients reported last month. However, the length of stay for this group was 30 percent longer, and their mortality rate was three-fold greater (See figure).
Hospital discharge status
The association between alcohol and injury is well known to the trauma community. Clinically, we are able to treat these patients’ injuries and support them through the DTs. Resources exist at many levels to offer assistance to those individuals with chronic alcohol problems. However, it is important to first identify those patients in need of help. A primer titled Alcohol Screening and Brief Intervention (SBI) for Trauma Patients, authored by the American College of Surgeons Committee on Trauma, The U.S. Department of Health and Human Services, and the Department of Transportation can be accessed online.
Throughout the year, we will be highlighting NTDB data through brief reports in the Bulletin. The National Trauma Data Bank 2013 Annual Report is available on the ACS website as a PDF file. In addition, information about how to obtain NTDB data for more detailed study is available on the website. To learn more about submitting your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at firstname.lastname@example.org.
Statistical support for this article has been provided by Crystal Caden-Price, Data Analyst, and Alice Rollins, NTDB Coordinator.
*Fantus R. Unanticipated withdrawal. Bull Am Coll Surg. 2014;99(10):48-49.
†Barrère Albert MV, Leland Charles G. A Dictionary of Slang, Jargon & Cant: Embracing English, American, and Anglo-Indian Slang, Pidgin English, Tinker’s Jargon and Other Irregular Phraseology. London: Ballantyne Press;1889:84.
‡MedlinePlus medical encyclopedia. Delirium tremens. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/000766.htm. Accessed August 31, 2014.