Delerium Tremens
   HOME

TheInfoList



OR:

Delirium tremens (DTs) is a rapid onset of confusion usually caused by withdrawal from alcohol. When it occurs, it is often three days into the withdrawal symptoms and lasts for two to three days. Physical effects may include shaking, shivering, irregular heart rate, and sweating. People may also
hallucinate A hallucination is a perception in the absence of an external stimulus that has the qualities of a real perception. Hallucinations are vivid, substantial, and are perceived to be located in external objective space. Hallucination is a combinati ...
. Occasionally, a very high body temperature or
seizure An epileptic seizure, informally known as a seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much of the body with l ...
s (colloquially known as "rum fits") may result in death. Alcohol is one of the most dangerous drugs to withdraw from. Delirium tremens typically only occurs in people with a high intake of alcohol for more than a month. A similar syndrome may occur with benzodiazepine and
barbiturate withdrawal Barbiturates are a class of depressant drugs that are chemically derived from barbituric acid. They are effective when used medically as anxiolytics, hypnotics, and anticonvulsants, but have physical and psychological addiction potential as ...
. Withdrawal from stimulants such as
cocaine Cocaine (from , from , ultimately from Quechua: ''kúka'') is a central nervous system (CNS) stimulant mainly used recreationally for its euphoric effects. It is primarily obtained from the leaves of two Coca species native to South Ameri ...
do not have major medical complications. In a person with delirium tremens it is important to rule out other associated problems such as
electrolyte abnormalities Electrolyte imbalance, or water-electrolyte imbalance, is an abnormality in the concentration of electrolytes in the body. Electrolytes play a vital role in maintaining homeostasis in the body. They help to regulate heart and neurological function, ...
,
pancreatitis Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. There are two main types: acute pancreatitis, and chronic pancr ...
, and
alcoholic hepatitis Alcoholic hepatitis is hepatitis (inflammation of the liver) due to excessive intake of alcohol. Patients typically have a history of at least 10 years of heavy alcohol intake, typically 8-10 drinks per day. It is usually found in association with ...
. Prevention is by treating withdrawal symptoms. If delirium tremens occurs, aggressive treatment improves outcomes. Treatment in a quiet
intensive care unit 220px, Intensive care unit An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensi ...
with sufficient light is often recommended. Benzodiazepines are the medication of choice with
diazepam Diazepam, first marketed as Valium, is a medicine of the benzodiazepine family that acts as an anxiolytic. It is commonly used to treat a range of conditions, including anxiety, seizures, alcohol withdrawal syndrome, muscle spasms, insomnia, ...
,
lorazepam Lorazepam, sold under the brand name Ativan among others, is a benzodiazepine medication. It is used to treat anxiety disorders, trouble sleeping, severe agitation, active seizures including status epilepticus, alcohol withdrawal, and c ...
,
chlordiazepoxide Chlordiazepoxide, trade name Librium among others, is a sedative and hypnotic medication of the benzodiazepine class; it is used to treat anxiety, insomnia and symptoms of withdrawal from alcohol and other drugs. Chlordiazepoxide has a medium t ...
, and
oxazepam Oxazepam is a short-to-intermediate-acting benzodiazepine. Oxazepam is used for the treatment of anxiety and insomnia and in the control of symptoms of alcohol withdrawal syndrome. It is a metabolite of diazepam, prazepam, and temazepam, and ha ...
all commonly used. They should be given until a person is lightly sleeping. The
antipsychotic Antipsychotics, also known as neuroleptics, are a class of psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), principally in schizophrenia but also in a range of ...
haloperidol Haloperidol, sold under the brand name Haldol among others, is a typical antipsychotic medication. Haloperidol is used in the treatment of schizophrenia, tics in Tourette syndrome, mania in bipolar disorder, delirium, agitation, acute psychosi ...
may also be used. The vitamin
thiamine Thiamine, also known as thiamin and vitamin B1, is a vitamin, an essential micronutrient, that cannot be made in the body. It is found in food and commercially synthesized to be a dietary supplement or medication. Phosphorylated forms of thi ...
is recommended. Mortality without treatment is between 15% and 40%. Currently death occurs in about 1% to 4% of cases. About half of people with
alcoholism Alcoholism is, broadly, any drinking of alcohol that results in significant mental or physical health problems. Because there is disagreement on the definition of the word ''alcoholism'', it is not a recognized diagnostic entity. Predomi ...
will develop withdrawal symptoms upon reducing their use. Of these, 3% to 5% develop DTs or have seizures. The name delirium tremens was first used in 1813; however, the symptoms were well described since the 1700s. The word "delirium" is
Latin Latin (, or , ) is a classical language belonging to the Italic branch of the Indo-European languages. Latin was originally a dialect spoken in the lower Tiber area (then known as Latium) around present-day Rome, but through the power of the ...
for "going off the furrow," a plowing metaphor. It is also called the shaking frenzy and Saunders-Sutton syndrome. There are numerous nicknames for the condition, including "the DTs" and "
seeing pink elephants "Seeing pink elephants" is a euphemism for hallucinations caused by delirium tremens or alcoholic hallucinosis, especially the former. The term dates back to at least the early 20th century, emerging from earlier idioms about seeing snakes and o ...
" (see below).


Signs and symptoms

The main symptoms of delirium tremens are nightmares, agitation, global confusion, disorientation, visual and auditory hallucinations,
tactile hallucination Tactile hallucination is the false perception of tactile sensory input that creates a hallucinatory sensation of physical contact with an imaginary object. It is caused by the faulty integration of the tactile sensory neural signals generated in th ...
s, fever, high blood pressure, heavy sweating, and other signs of autonomic hyperactivity (
fast heart rate Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal (su ...
and high blood pressure). These symptoms may appear suddenly but typically develop two to three days after the stopping of heavy drinking, being worst on the fourth or fifth day. These symptoms are characteristically worse at night. In general, DT is considered the most severe manifestation of alcohol withdrawal and occurs 3–10 days following the last drink. Other common symptoms include intense perceptual disturbance such as visions of insects, snakes, or rats. These may be hallucinations or illusions related to the environment, e.g., patterns on the wallpaper or in the peripheral vision that the patient falsely perceives as a resemblance to the morphology of an insect, and are also associated with tactile hallucinations such as sensations of something crawling on the subject—a phenomenon known as formication. Delirium tremens usually includes extremely intense feelings of "impending doom". Severe anxiety and feelings of imminent death are common DT symptoms. DT can sometimes be associated with severe, uncontrollable tremors of the extremities and secondary symptoms such as anxiety, panic attacks, and
paranoia Paranoia is an instinct or thought process that is believed to be heavily influenced by anxiety or fear, often to the point of delusion and irrationality. Paranoid thinking typically includes persecutory beliefs, or beliefs of conspiracy co ...
. Confusion is often noticeable to onlookers as those with DT will have trouble forming simple sentences or making basic logical calculations. DT should be distinguished from
alcoholic hallucinosis Alcoholic hallucinosis is a complication of alcohol misuse in people with alcohol use disorder. It can occur during acute intoxication or withdrawal with the potential of having delirium tremens. Alcohol hallucinosis is a rather uncommon alcohol- ...
, the latter of which occurs in approximately 20% of hospitalized alcoholics and does not carry a risk of significant mortality. In contrast, DT occurs in 5–10% of alcoholics and carries up to 15% mortality with treatment and up to 35% mortality without treatment.


Causes

Delirium tremens is mainly caused by a long period of drinking being stopped abruptly. Withdrawal leads to a biochemical regulation cascade. Delirium tremens is most common in people who are in
alcohol withdrawal Alcohol withdrawal syndrome (AWS) is a set of symptoms that can occur following a reduction in alcohol use after a period of excessive use. Symptoms typically include anxiety, shakiness, sweating, vomiting, fast heart rate, and a mild fever. M ...
, especially in those who drink the equivalent of of beer or of distilled beverage daily. Delirium tremens commonly affects those with a history of habitual alcohol use or alcoholism that has existed for more than 10 years.


Pathophysiology

Delirium tremens is a component of alcohol withdrawal hypothesized to be the result of compensatory changes in response to chronic heavy alcohol use. Alcohol positively allosterically modulates the binding of GABA, enhancing its effect and resulting in inhibition of neurons projecting into the
nucleus accumbens The nucleus accumbens (NAc or NAcc; also known as the accumbens nucleus, or formerly as the ''nucleus accumbens septi'', Latin for " nucleus adjacent to the septum") is a region in the basal forebrain rostral to the preoptic area of the hypot ...
, as well as inhibiting NMDA receptors. This combined with desensitization of
alpha-2 adrenergic receptor The alpha-2 (α2) adrenergic receptor (or adrenoceptor) is a G protein-coupled receptor (GPCR) associated with the Gi heterotrimeric G-protein. It consists of three highly homologous subtypes, including α2A-, α2B-, and α2C-adrenergic. Some ...
s, results in a homeostatic upregulation of these systems in chronic alcohol use. When alcohol use ceases, the unregulated mechanisms result in hyperexcitability of neurons as natural GABAergic systems are down-regulated and excitatory
glutamatergic Glutamatergic means "related to glutamate". A glutamatergic agent (or drug) is a chemical that directly modulates the excitatory amino acid (glutamate/aspartate) system in the body or brain. Examples include excitatory amino acid receptor agonis ...
systems are unregulated. This combined with increased noradrenergic activity results in the symptoms of delirium tremens.


Diagnosis

Diagnosis is mainly based on symptoms. In a person with delirium tremens it is important to rule out other associated problems such as
electrolyte abnormalities Electrolyte imbalance, or water-electrolyte imbalance, is an abnormality in the concentration of electrolytes in the body. Electrolytes play a vital role in maintaining homeostasis in the body. They help to regulate heart and neurological function, ...
,
pancreatitis Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. There are two main types: acute pancreatitis, and chronic pancr ...
, and
alcoholic hepatitis Alcoholic hepatitis is hepatitis (inflammation of the liver) due to excessive intake of alcohol. Patients typically have a history of at least 10 years of heavy alcohol intake, typically 8-10 drinks per day. It is usually found in association with ...
.


Treatment

Delirium tremens due to alcohol withdrawal can be treated with benzodiazepines. High doses may be necessary to prevent death. Amounts given are based on the symptoms. Typically the person is kept sedated with benzodiazepines, such as
diazepam Diazepam, first marketed as Valium, is a medicine of the benzodiazepine family that acts as an anxiolytic. It is commonly used to treat a range of conditions, including anxiety, seizures, alcohol withdrawal syndrome, muscle spasms, insomnia, ...
,
lorazepam Lorazepam, sold under the brand name Ativan among others, is a benzodiazepine medication. It is used to treat anxiety disorders, trouble sleeping, severe agitation, active seizures including status epilepticus, alcohol withdrawal, and c ...
,
chlordiazepoxide Chlordiazepoxide, trade name Librium among others, is a sedative and hypnotic medication of the benzodiazepine class; it is used to treat anxiety, insomnia and symptoms of withdrawal from alcohol and other drugs. Chlordiazepoxide has a medium t ...
, or
oxazepam Oxazepam is a short-to-intermediate-acting benzodiazepine. Oxazepam is used for the treatment of anxiety and insomnia and in the control of symptoms of alcohol withdrawal syndrome. It is a metabolite of diazepam, prazepam, and temazepam, and ha ...
. In some cases
antipsychotics Antipsychotics, also known as neuroleptics, are a class of psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), principally in schizophrenia but also in a range of ...
, such as
haloperidol Haloperidol, sold under the brand name Haldol among others, is a typical antipsychotic medication. Haloperidol is used in the treatment of schizophrenia, tics in Tourette syndrome, mania in bipolar disorder, delirium, agitation, acute psychosi ...
may also be used. Older drugs such as
paraldehyde Paraldehyde is the cyclic trimer of acetaldehyde molecules. Formally, it is a derivative of 1,3,5-trioxane, with a methyl group substituted for a hydrogen atom at each carbon. The corresponding tetramer is metaldehyde. A colourless liquid, it ...
and
clomethiazole Clomethiazole (also called chlormethiazole or Heminevrin) is a sedative and hypnotic originally developed by Hoffmann-La Roche in the 1930s. The drug is used in treating and preventing symptoms of acute alcohol withdrawal. It is structurally r ...
were formerly the traditional treatment but have now largely been superseded by the benzodiazepines.
Acamprosate Acamprosate, sold under the brand name Campral, is a medication used along with counselling to treat alcohol use disorder. For label updates seFDA index page for NDA 021431/ref> Acamprosate is thought to stabilize chemical signaling in the brai ...
is occasionally used in addition to other treatments, and is then carried on into long-term use to reduce the risk of relapse. If status epilepticus occurs it is treated in the usual way. It can also be helpful to provide a well lit room as people often have hallucinations. Alcoholic beverages can also be prescribed as a treatment for delirium tremens, but this practice is not universally supported. High doses of
thiamine Thiamine, also known as thiamin and vitamin B1, is a vitamin, an essential micronutrient, that cannot be made in the body. It is found in food and commercially synthesized to be a dietary supplement or medication. Phosphorylated forms of thi ...
often by the intravenous route is also recommended.


Society and culture

Nicknames for delirium tremens include "the DTs", "the shakes", "the oopizootics", "barrel-fever", "the blue horrors", "bottleache", "bats", "the drunken horrors", "
seeing pink elephants "Seeing pink elephants" is a euphemism for hallucinations caused by delirium tremens or alcoholic hallucinosis, especially the former. The term dates back to at least the early 20th century, emerging from earlier idioms about seeing snakes and o ...
", "gallon distemper", "quart mania", "heebie jeebies", "pink spiders", and "riding the ghost train", as well as "ork orks", "the zoots", "the 750 itch", and "pint paralysis". Another nickname is "the
Brooklyn Brooklyn () is a borough of New York City, coextensive with Kings County, in the U.S. state of New York. Kings County is the most populous county in the State of New York, and the second-most densely populated county in the United States, be ...
Boys", found in
Eugene O'Neill Eugene Gladstone O'Neill (October 16, 1888 – November 27, 1953) was an American playwright and Nobel laureate in Nobel Prize in Literature, literature. His poetically titled plays were among the first to introduce into the U.S. the drama tech ...
's one-act play '' Hughie'' set in
Times Square Times Square is a major commercial intersection, tourist destination, entertainment hub, and neighborhood in Midtown Manhattan, New York City. It is formed by the junction of Broadway, Seventh Avenue, and 42nd Street. Together with adjacent ...
in the 1920s. Delirium tremens was also given an alternate medical definition since at least the 1840s, being known as '' mania a potu'', which translates to 'mania from drink'. English author
George Eliot Mary Ann Evans (22 November 1819 – 22 December 1880; alternatively Mary Anne or Marian), known by her pen name George Eliot, was an English novelist, poet, journalist, translator, and one of the leading writers of the Victorian era. She wrot ...
provides a case involving delirium tremens in her novel ''
Middlemarch ''Middlemarch, A Study of Provincial Life'' is a novel by the English author Mary Anne Evans, who wrote as George Eliot. It first appeared in eight installments (volumes) in 1871 and 1872. Set in Middlemarch, a fictional English Midland town, ...
'' (187172). Alcoholic scoundrel John Raffles, both an abusive stepfather of Joshua Riggs and blackmailing nemesis of financier Nicholas Bulstrode, dies, whose "death was due to delirium tremens" while at Peter Featherstone's Stone Court property. Housekeeper Mrs. Abel provides Raffles' final night of care per Bulstrode's instruction whose directions given to Abel stand adverse to Dr. Tertius Lydgate's orders. French writer
Émile Zola Émile Édouard Charles Antoine Zola (, also , ; 2 April 184029 September 1902) was a French novelist, journalist, playwright, the best-known practitioner of the literary school of naturalism, and an important contributor to the development of ...
's novel ''The Drinking Den'' (''
L'Assommoir ''L'Assommoir'' , published as a serial in 1876, and in book form in 1877, is the seventh novel in Émile Zola's twenty-volume series ''Les Rougon-Macquart''. Usually considered one of Zola's masterpieces, the novel — a study of alcoholism and po ...
'') includes a character – Coupeau, the main character Gervaise's husband – who has delirium tremens by the end of the book. American writer Mark Twain describes an episode of delirium tremens in his book ''The Adventures of Huckleberry Finn'' (1884). In chapter 6, Huck states about his father, "After supper pap took the jug, and said he had enough whisky there for two drunks and one delirium tremens. That was always his word." Subsequently, Pap Finn runs around with hallucinations of snakes and chases Huck around their cabin with a knife in an attempt to kill him, thinking Huck is the "Angel of Death". One of the characters in Joseph Conrad's novel ''
Lord Jim ''Lord Jim'' is a novel by Joseph Conrad originally published as a serial in ''Blackwood's Magazine'' from October 1899 to November 1900. An early and primary event in the story is the abandonment of a passenger ship in distress by its crew, ...
'' experiences "DTs of the worst kind" with symptoms that include seeing millions of pink frogs. English author
M. R. James Montague Rhodes James (1 August 1862 – 12 June 1936) was an English author, medievalist scholar and provost of King's College, Cambridge (1905–1918), and of Eton College (1918–1936). He was Vice-Chancellor of the University of Cambrid ...
mentions delirium tremens in his 1904 ghost story
'Oh, Whistle, and I'll Come to You, My Lad' "Oh, Whistle, and I'll Come to You, My Lad" is a ghost story by British writer M. R. James, included in his collection ''Ghost Stories of an Antiquary'' (1904). The story is named after a 1793 poem of the same name penned by Robert Burns. Plot ...
. Professor Parkins while staying at the Globe Inn when in coastal Burnstow to "improve his game" of golf, despite being "a convinced disbeliever in what is called the 'supernatural, when face to face with an entity in his "double-bed room" during the story's climax, is heard "uttering cry upon cry at the utmost pitch of his voice" though later "was somehow cleared of the ready suspicion of delirium tremens". In the 1945 film '' The Lost Weekend'', Ray Milland won the Academy Award for Best Actor for his depiction of a character who experiences delirium tremens after being hospitalized, hallucinating that he saw a bat fly in and eat a mouse poking through a wall. Writer Jack Kerouac details his experiences with delirium tremens in his book '' Big Sur''. The ''
M*A*S*H ''M*A*S*H'' (Mobile Army Surgical Hospital) is an American media franchise consisting of a series of novels, a film, several television series, plays, and other properties, and based on the semi-autobiographical fiction of Richard Hooker. Th ...
'' TV series episode "Bottoms Up" (season 9, episode 15) featured a side story about a nurse (Cpt. Helen Whitfield) who was found to be drinking heavily off-duty. By the culmination of the episode, after a confrontation by Maj. Margaret Houlihan, the character swears off alcohol and presumably quits immediately. At mealtime, roughly 48 hours later, Whitfield becomes hysterical upon being served food in the Mess tent, claiming that things are crawling onto her from it. Margaret and Col. Sherman Potter subdue her. Potter, having recognized the symptoms of delirium tremens orders 5 ml of
paraldehyde Paraldehyde is the cyclic trimer of acetaldehyde molecules. Formally, it is a derivative of 1,3,5-trioxane, with a methyl group substituted for a hydrogen atom at each carbon. The corresponding tetramer is metaldehyde. A colourless liquid, it ...
from a witnessing nurse. During the filming of the 1975 film '' Monty Python and the Holy Grail'',
Graham Chapman Graham Chapman (8 January 1941 – 4 October 1989) was a British actor, comedian and writer. He was one of the six members of the surreal comedy group Monty Python. He portrayed authority figures such as The Colonel and the lead role in two P ...
developed delirium tremens due to the lack of alcohol on the set. It was particularly bad during the filming of the bridge of death scene where Chapman was visibly shaking, sweating and could not cross the bridge. His fellow Pythons were astonished as Chapman was an accomplished mountaineer. Irish singer-songwriter
Christy Moore Christopher Andrew "Christy" Moore (born 7 May 1945) is an Irish folk singer, songwriter and guitarist. In addition to his significant success as an individual, he is one of the founding members of Planxty and Moving Hearts. His first album, ...
has a song on his 1985 album, '' Ordinary Man'', called "Delirium Tremens" which is a satirical song, directed towards the leaders in Irish politics and culture. Some of the people mentioned in the song include former Fianna Fáil leader
Charles Haughey Charles James Haughey (; 16 September 1925 – 13 June 2006) was an Irish Fianna Fáil politician who served as Taoiseach on three occasions – 1979 to 1981, March to December 1982 and 1987 to 1992. He was also Minister for the Gaeltacht from ...
, at the time a Labour TD, later the party leader
Ruairi Quinn Ruairi Quinn (born 2 April 1946) is an Irish former Labour Party politician who served as Minister for Education and Skills from 2011 to 2014, Leader of the Labour Party from 1997 to 2002, Deputy Leader of the Labour Party from 1989 to 1997, ...
, former Labour Party leader
Dick Spring Dick Spring (born 29 August 1950) is an Irish businessman and former politician. He was a Labour Party Teachta Dála (TD) for the Kerry North from 1981 to 2002. He became leader of the Labour Party in 1982, and held this position until 1997 ...
and
Roger Casement Roger David Casement ( ga, Ruairí Dáithí Mac Easmainn; 1 September 1864 – 3 August 1916), known as Sir Roger Casement, CMG, between 1911 and 1916, was a diplomat and Irish nationalist executed by the United Kingdom for treason during Worl ...
, who was captured bringing German guns to Ireland for the
1916 Easter Rising The Easter Rising ( ga, Éirí Amach na Cásca), also known as the Easter Rebellion, was an armed insurrection in Ireland during Easter Week in April 1916. The Rising was launched by Irish republicans against British rule in Ireland with the ...
. The Belgian beer "Delirium Tremens," introduced in 1988, is a direct reference and also uses a pink elephant as its logo to highlight one of the symptoms of delirium tremens. In the 1995 film ''
Leaving Las Vegas ''Leaving Las Vegas'' is a 1995 American drama film written and directed by Mike Figgis, and based on the semi-autobiographical 1990 novel of the same name by John O'Brien. Nicolas Cage stars as a suicidal alcoholic in Los Angeles who, having ...
'',
Nicolas Cage Nicolas Kim Coppola (born January 7, 1964), known professionally as Nicolas Cage, is an American actor and film producer. Born into the Coppola family, he is the recipient of various accolades, including an Academy Award, a Screen Actors Gui ...
plays a suicidal alcoholic who rids himself of all his possessions and travels to Las Vegas to drink himself to death. During his travels, he experiences delirium tremens on a couch after waking up from a binge and crawls in pain to the refrigerator for more
vodka Vodka ( pl, wódka , russian: водка , sv, vodka ) is a clear distilled alcoholic beverage. Different varieties originated in Poland, Russia, and Sweden. Vodka is composed mainly of water and ethanol but sometimes with traces of impuriti ...
. Cage's performance as Ben Sanderson in the film won the Academy Award for Best Actor in 1996. Russian composer
Modest Mussorgsky Modest Petrovich Mussorgsky ( rus, link=no, Модест Петрович Мусоргский, Modest Petrovich Musorgsky , mɐˈdɛst pʲɪˈtrovʲɪtɕ ˈmusərkskʲɪj, Ru-Modest Petrovich Mussorgsky version.ogg; – ) was a Russian compo ...
(1839-1881) died of delirium tremens.


See also

* Alcohol dementia *
Alcohol detoxification Alcohol detoxification (also known as ''detox'') is the abrupt cessation of alcohol intake in individuals that have alcohol dependence. This process is often coupled with substitution of drugs that have effects similar to the effects of alcohol i ...
* Delusional parasitosis *
Excited delirium Excited delirium (ExDS), also known as agitated delirium (AgDS), is a controversial diagnosis sometimes characterized as a potentially fatal state of extreme agitation and delirium. It is typically diagnosed postmortem in young adult males, dispr ...
* On the wagon


References


External links


Why Does Alcohol Cause the Shakes?
, Alcohol Withdrawal Syndrome Tremors , Dr Peter MCcann MCC, MBBS , Castle Craig Hospital {{DEFAULTSORT:Delirium Tremens Health effects of alcohol Addiction psychiatry Intensive care medicine Neurological disorders Latin medical words and phrases Medical emergencies Alcohol abuse Wikipedia medicine articles ready to translate Wikipedia emergency medicine articles ready to translate