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Describe delirium tremens with its features and medicolegal importance.

Forensic Medicine · 2nd Professional — Para-Clinical

Nature and Features

Delirium tremens is the most severe form of alcohol withdrawal, occurring in a chronic dependent drinker 48 to 96 hours after the last drink, and characterised by delirium, tremor, autonomic overactivity and vivid hallucinations. It carries a mortality of up to 5 to 15% if untreated.

Precipitants — abrupt cessation or marked reduction of drinking, very often because the person has been admitted to hospital, arrested or imprisoned, or has become ill and stopped; intercurrent infection, trauma, surgery and pancreatitis
The timeline of withdrawal — tremor, sweating and anxiety at 6 to 12 hours; alcoholic hallucinosis with clear consciousness at 12 to 24 hours; seizures ("rum fits") at 24 to 48 hours; and delirium tremens at 48 to 96 hours

Feature	Description
Clouding of consciousness	Disorientation in time and place, fluctuating, and worse AT night — the defining feature that distinguishes it from alcoholic hallucinosis, in which consciousness is clear
Coarse tremor	Of the hands, tongue and whole body — the "trembling delirium"
Hallucinations — characteristically visual	Vivid, terrifying and often of small animals — snakes, rats and insects (lilliputian hallucinations); and tactile, with formication, the sensation of insects crawling on and under the skin
Fleeting persecutory delusions	Arising from the hallucinations, and driving the behaviour
Extreme fear and agitation	The person may attack imagined assailants, or flee and jump from a window — the mechanism of most of the deaths and injuries associated with the condition
Autonomic overactivity	Fever, tachycardia, hypertension, profuse sweating and dehydration; and seizures
Insomnia	Complete and characteristic

CLINICAL PEARL

Alcoholic hallucinosis has a clear sensorium and delirium tremens does not, and the difference is the diagnosis. In hallucinosis the person is fully orientated, hears voices, and is not tremulous or febrile. In delirium tremens consciousness is clouded and fluctuating, the hallucinations are visual, and there is tremor and autonomic storm. The second is a medical emergency with real mortality; the first is not.

Medicolegal Importance

Criminal responsibility — delirium tremens is a genuine unsoundness OF mind and may found a defence under BNS 22. It has to be separated carefully from simple voluntary intoxication, which is NO defence under BNS 24: the first is a disease state arising from chronic dependence and withdrawal, the second is a self-induced condition
Violence and homicide in response to terrifying hallucinations and persecutory delusions; the acts are typically defensive in the person’s own mind
Accidental death and injury — falls, and jumping from a height to escape imagined pursuers, which is the characteristic mechanism
Suicide during the episode
Death IN custody — a matter of real importance. A dependent drinker arrested and held in a police station or prison stops drinking abruptly and develops delirium tremens within days; untreated, this kills. Such a death is a custodial death requiring a magistrate’s inquest, a board autopsy and videography, and may raise a question of negligence in failing to recognise and treat the withdrawal
Civil capacity — a contract or will made during an episode is invalid; one made in a lucid interval is not
Testamentary and consent capacity are absent during the episode

Management and Applied Aspects

Treat as a medical emergency — long-acting benzodiazepines (chlordiazepoxide or diazepam) in adequate doses, guided by a withdrawal scale; correction of fluid and electrolytes; and a quiet, well-lit room with reassurance and constant observation
Give parenteral thiamine before any glucose; administering glucose to a thiamine-deficient alcoholic precipitates wernicke encephalopathy, which is preventable, irreversible if missed, and a recurring cause of avoidable catastrophe
Search for a precipitating illness — infection, head injury, gastrointestinal bleeding, hepatic failure, pancreatitis and subdural haematoma — which are common in this population and may be the real problem
Ask about alcohol IN every person taken into custody, and arrange prophylaxis for a dependent drinker; withdrawal in custody is predictable, preventable and lethal, and its occurrence reflects a failure of the system rather than of the patient
Distinguish it from simple drunkenness in a report; the two have opposite legal consequences and are confused constantly
Avoid physical restraint where possible; it increases agitation, hyperthermia and rhabdomyolysis, and positional restraint has itself caused deaths

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