Delirium Tremens (DTs): Signs, Timing, Treatment, and Why It Is a 911 Call

What are delirium tremens?

Delirium tremens, or the DTs, is the most serious form of alcohol withdrawal: a sudden, severe confusion that arrives days after the last drink, with the body running hot and fast. MedlinePlus calls it a medical emergency that needs a hospital stay. ASAM’s 2020 alcohol withdrawal guideline names seizure, delirium and death as the most severe consequences of alcohol withdrawal.

Clinicians call it alcohol withdrawal delirium. “Tremens” is the shaking. The delirium is the part that matters: a person who cannot follow what is happening may hurt themselves or others, and cannot reliably report their own symptoms.

Signs of delirium tremens

MedlinePlus lists these, and says they can get worse quickly:

Shaking, sweating, anxiety and a fast pulse are on MedlinePlus’s list of ordinary alcohol withdrawal symptoms too. Sudden, severe confusion is what marks the DTs. A person who was miserable but clear yesterday and is lost today needs 911, not another night of watching.

DTs vs alcohol hallucinations

Hallucinations alone are not always the DTs. ASAM tells clinicians to try to distinguish withdrawal delirium from alcohol hallucinosis, which ASAM describes as hallucinations, mostly voices, that occur in clear consciousness and without delirium, and to rule out other causes of delirium with a full medical and neurological workup, whatever the apparent cause. MedlinePlus notes that a head injury, infection or illness can trigger the DTs in someone with a history of heavy drinking. Family at home cannot do that sorting. A hospital can.

When do the DTs start?

MedlinePlus: symptoms most often occur 48 to 96 hours after the last drink, but may occur 7 to 10 days after it. Withdrawal seizures come earlier, most often in the first 12 to 48 hours.

The DTs can start after the early withdrawal has begun to ease, so a better morning is not the all-clear. Our alcohol withdrawal timeline walks through the hours and days in order. The short version: supervision runs through at least the first week.

Who is at risk for delirium tremens?

MedlinePlus says the DTs occur most often in people with a history of alcohol withdrawal, and are especially common in people who have drunk heavily every day for several months (it gives 4 to 5 pints of wine, 7 to 8 pints of beer, or 1 pint of liquor a day as examples). They also commonly affect people who have used alcohol for more than 10 years. ASAM’s risk factors for severe or complicated withdrawal include:

• A past withdrawal seizure or delirium tremens. ASAM notes strong evidence behind this one.
• Many past withdrawal episodes, or long, heavy, daily drinking.
• A serious medical or surgical illness, especially a traumatic brain injury.
• Age over 65.
• A seizure during this withdrawal, or a racing heart, high blood pressure or heavy sweating at arrival.
• Dependence on benzodiazepines or other sedatives, or use of other drugs.
• Withdrawal symptoms while alcohol is still in the blood.

Anyone with the first item on that list needs a supervised setting to stop drinking, not a home detox. Our page on detoxing from alcohol at home covers who can and who cannot.

Can you die from delirium tremens?

Yes. MedlinePlus calls the DTs serious and possibly life-threatening, and lists irregular heartbeat, seizures, falls and injuries from confusion among the complications. What changes the odds is treatment.

The 2004 review says evidence suggests appropriate care improves mortality. The Spanish and U.S. trauma studies show that treatment lowers the risk without removing it. You will see much higher death rates for untreated DTs quoted elsewhere, usually as a single percentage. We could not trace those figures to a primary study we could read, so we have left them out.

The Norway study looks past the episode itself. It linked hospital and death records for more than 36,000 patients, and the DTs group had the highest death rate of the three groups studied, with especially high rates of unnatural deaths. A DTs episode is a reason to treat the drinking, not only the withdrawal.

How delirium tremens is treated

In a hospital, and often in intensive care. ASAM says people with withdrawal delirium need close nursing observation and supportive care, which often means an intensive or critical care unit, and that agitated, disoriented patients should have one-to-one observation.

• Benzodiazepines first. ASAM names them first-line, given to keep the person in light somnolence. It warns that very large doses may be needed, much higher than in other patients, and that clinicians should not hesitate to use them while watching for oversedation and slowed breathing.
• Through a vein. ASAM calls for immediate IV access for fluids and medication.
• Phenobarbital as a backup. Barbiturates are an alternative, not preferred, and phenobarbital can be added when benzodiazepines alone do not control the delirium in a closely monitored setting.
• Antipsychotics only as add-ons. ASAM does not recommend them alone for withdrawal delirium, which matches the 2004 finding on deaths.
• Thiamine. ASAM recommends it to prevent Wernicke encephalopathy, a brain injury caused by thiamine deficiency.

MedlinePlus adds the ordinary hospital work: checking blood chemistry, fluids, temperature, pulse, breathing and blood pressure, and treating seizures. Once the delirium clears, treatment for the drinking itself should begin.

The CIWA scale, in plain words

Detox staff score alcohol withdrawal with a checklist, most often the CIWA-Ar, a 10-item scale published in 1989. Staff rate things the patient shows, such as tremor, sweating and agitation, and things the patient reports, such as nausea, anxiety, headache, and strange sensations or sounds. A higher score means worse withdrawal. The alcohol detox guide shows the example score bands ASAM uses and which setting each points to.

Three limits matter for the DTs:

1. Once someone is delirious, the score stops meaning much. ASAM does not recommend the CIWA-Ar in patients with delirium, because it relies on patient-reported symptoms. ASAM recommends tools built for confused or sedated patients instead, such as the Richmond Agitation-Sedation Scale (RASS) or the Confusion Assessment Method for the ICU (CAM-ICU).
2. ASAM says withdrawal scales should not be used to diagnose withdrawal, because other conditions can raise the score.
3. A severity score shows how someone is doing right now. A low score on day one does not rule out delirium on day three or later.

That is why history matters as much as the number. Tell the intake team about every past seizure, every past bout of DTs, and every other substance, including prescribed sedatives.

What family can do

• Do not wait out confusion, hallucinations, a seizure or a fever. Call 911.
• If the person goes to a hospital for something else, such as a fall or an infection, tell the staff how much they have been drinking. MedlinePlus asks for exactly this, so the team can watch for withdrawal.
• Keep watching through the first week, even if day two looked better.
• Once the person is clear-headed, ask the team about medication for the drinking. Three are approved in the U.S.: naltrexone, acamprosate and disulfiram, and NIAAA notes that none of them is addictive. Our naltrexone, Vivitrol and Antabuse guide and acamprosate guide compare them.

In New Jersey

The emergency room is a legitimate way in. Federal law (EMTALA) covers hospitals with an emergency department that take Medicare. They must screen anyone who asks for emergency care and stabilize an emergency condition, whether or not the person can pay. Our hospital detox guide covers the New Jersey units that admit people for withdrawal.

Under New Jersey law P.L.2017, c.28, fully insured New Jersey plans and the State Health Benefits and School Employees’ plans cannot require prior authorization for the first 180 days per plan year of in-network treatment your own physician, psychologist or psychiatrist finds medically necessary, or, during those same 180 days, for outpatient prescription drugs that treat substance use disorder, such as buprenorphine and naltrexone, when that clinician finds them medically necessary. Self-funded employer plans, Medicare and Medicaid are not covered by that rule, so verify with the plan.

For most NJ FamilyCare members, hospital and outpatient detox go through the member’s health plan, and residential detox is authorized through the IME. Residential care is scheduled to move into the NJ FamilyCare health plans in January 2027. The alcohol detox guide lists New Jersey’s licensed programs that treat alcohol withdrawal.

For help independent of us, the state’s IME Addictions Access Center at 1-844-276-2777 screens NJ FamilyCare and uninsured residents and refers them to treatment, and ReachNJ, the state treatment line, is at 1-844-732-2465. Periscope Behavioral Health, which publishes this site, is opening a medical detox in Hammonton, Atlantic County, expected Summer 2027. Until it opens, Periscope Behavioral Health at (888) 313-3583, our publisher’s admissions line, can talk through options in New Jersey and Florida, including facilities Periscope operates. What a plan covers depends on the plan and the facility’s network status.

None of those phone lines replaces 911 for someone who is confused, seizing or burning up. Call the lines to plan a detox. Call 911 for the DTs.