White fever, or alcoholic delirium.

Delirium tremens, or acute alcohol-induced psychosis, is observed in patients with alcohol dependence in stages II-III of the disease and is characterized by a combination of delirious syndrome and pronounced somatovegetative and neurological disorders.

What causes delirium tremens?

The main causes of delirium tremens:

• heavy and prolonged binges;
• use of alcohol substitutes;
• pronounced somatic pathology;
• organic brain damage.

The pathogenesis of alcoholic delirium is not fully known; presumably, a major influence is exerted by a disruption in the metabolism of neurotransmitters in the central nervous system and severe, primarily endogenous, intoxication.

Symptoms of delirium tremens

According to epidemiological studies, the first delirium tremens most often develops no earlier than 7-10 years of the advanced stage of alcoholism. Alcoholic delirium usually develops at the height of alcohol withdrawal syndrome (most often on the 2nd-4th day) and, as a rule, manifests itself in the evening or at night. Early signs of the onset of delirium tremens are restlessness and fidgeting of the patient, severe anxiety and persistent insomnia. Signs of excitation of the sympathoadrenal system increase - paleness of the skin, often with a bluish tint, tachycardia and arterial hypertension, hyperhidrosis, moderate hyperthermia. Always present vegetative disorders (ataxia, muscle hypotonia, hyperreflexia, tremor) are expressed to one degree or another. Characteristic disturbances of water-electrolyte balance (dehydration, hyperazotemia, metabolic acidosis, etc.), changes in the blood picture (leukocytosis, shift in the leukocyte formula to the left, increased erythrocyte sedimentation rate, increased bilirubin levels, etc.), and subfebrile temperature are observed.

Vegetative and neurological disorders occur before the appearance of disorders of consciousness and persist for a long time after their reduction. Then, pareidolic illusions (flat images of changeable, often fantastic content, usually based on a really existing drawing, ornament, etc.) join the disorders described above. Illusory perception of the surrounding environment quickly gives way to the appearance of visual hallucinations. Psychotic disorders can be unstable: when the patient is activated, hallucinatory disorders can be reduced for a time and even disappear completely.

Reduced forms of delirium tremens

Hypnagogic delirium is characterized by numerous vivid, scene-like dreams or visual hallucinations when falling asleep or closing the eyes. An increase in psychotic symptoms is noted in the evening and at night, characterized by mild fear, an affect of surprise, and somatovegetative symptoms typical of delirious disorder. The content of hallucinations is varied: there may be frightening pictures (for example, a dangerous chase) and adventurous adventures. In some cases, the patient is transferred to a hallucinatory environment, which indicates partial disorientation. When opening the eyes or waking up, a critical attitude to what was seen is not restored immediately and this can affect the patient's behavior and statements. Hypnagogic delirium tremens usually lasts 1-2 nights and can be replaced by alcoholic psychoses of varying structure and form.

Hypnagogic delirium tremens of fantastic content (hypnagogic oneirism) differs from the above-described variant by the fantastic content of abundant, sensually vivid visual hallucinations, scene-like hallucinatory disorders with a sequential change of situations. It is noteworthy: when opening the eyes, dreams are interrupted, and when closing them, they resume again, and thus, the development of the hallucinatory episode is not interrupted. In this form of delirium, the affect of fear, rather than interest and surprise, often predominates. Another distinctive feature is disorientation in the surroundings (as a constant symptom). The duration and outcomes are similar to the variant of hypnagogic delirium.

Hypnagogic delirium tremens and hypnagogic onirism are not identified in ICD-10 as separate nosological forms.

Delirium without delirium, delirium tremens without delirium tremens (delirium lucidum, shaking syndrome) - I. Salum. (1972) (F10.44*) - an atypical form characterized by the absence of hallucinations and delirium in the clinical picture. It occurs acutely. The main disorders contain neurological symptoms expressed to a significant degree: distinct, coarse tremor, ataxia, sweating. Disorientation in time and space is transient. The affect of anxiety and fear is constant. Confusion, fussiness, restlessness, agitation prevail in behavior. The course of this form of delirium is short-term - 1-3 days, recovery is often critical. Transition to other forms of delirium is possible.

In abortive delirium tremens (F0.46*), prodromal phenomena are usually absent. The clinical picture includes isolated visual illusions and microscopic hallucinations; of other hallucinatory disorders, akoasmas and phonemes are most often observed. The affect of anxiety and fear is characteristic similarly to other forms of delirious clouding of consciousness. Delusional disorders are rudimentary, behavioral disorders are inconstant, transient. Neurological disorders are not sharply expressed.

In the case of abortive delirium and relatively shallow clouding of consciousness, patients may have critical doubts about the reality of what is happening, even during hallucinatory experiences. The degree of criticality of the patient to the experiences he has experienced increases as he recovers and the associated disappearance of delirious symptoms. The duration of abortive delirium is up to 1 day. The exit is critical.

Typical or classic delirium tremens

With typical delirium tremens, the symptoms flicker from several hours to a day, after which the hallucinations become permanent. Alcoholic delirium undergoes several successive stages in its development.

Prodromal period

During this period, which usually lasts several days, sleep disorders (nightmarish, frightening dreams, fears) predominate, a changeable affect with prevalence is characteristic, asthenic complaints are constant. In 20% of cases, the development of delirium tremens is preceded by major and, less often, abortive epileptic seizures, which often occur on the first or second day of the existence of alcohol withdrawal syndrome. On the 3rd-4th day from the onset of alcohol withdrawal syndrome, epileptic seizures are rare. In other cases, delirium may develop after an episode of verbal hallucinations or an outbreak of acute sensory delirium. When diagnosing alcoholic delirium, one should not forget about the possible absence of a prodromal period. I

First stage

The mood changes present in the prodrome of the disease become more noticeable, a rapid change of opposite affects is observed: depression, anxiety or timidity are easily replaced by euphoria, causeless joy. Patients are excessively talkative, restless, fidgety (akathasia). Speech is fast, inconsistent, slightly incoherent, attention is easily distracted. Facial expressions and movements are lively, fast, sharply changeable. Disorientation or incomplete orientation in place and time are often observed. Orientation in one's own personality, as a rule, is preserved even at the advanced stages of delirium tremens. Patients are characterized by mental hyperesthesia - a sharp increase in susceptibility to the influence of various stimuli, sometimes even indifferent ones. There are influxes of vivid memories, figurative representations, visual illusions; Sometimes episodes of auditory hallucinations in the form of akoasms and phonemes occur, various elements of figurative delirium are noted, by the evening all symptoms increase sharply. Night sleep is disturbed, frequent awakenings in a state of anxiety are observed.

Emotional and psychomotor agitation, rapid change of affect are significant diagnostic signs for distinguishing delirium tremens from alcohol withdrawal syndrome with a predominance of the mental component. In differential diagnostics, it is necessary to distinguish the initial stage of development of delirium tremens and a hangover state, characterized by a typical monotonous depressed-anxious affect.

Second stage

The clinical picture of stage 1 is joined by pareidolia - visual illusions of fantastic content. They can be black and white or colored, static or dynamic. Hypnagogic hallucinations of varying intensity are characteristic. Sleep is still intermittent, with frightening dreams. During awakenings, the patient cannot immediately distinguish a dream from reality. Hyperesthesia increases, photophobia increases. Light intervals are possible, but they are short-lived. Dream-like experiences alternate with a state of relative wakefulness, with stupefaction.

Third stage

At stage III, complete insomnia is observed, and true visual hallucinations occur. Characteristic are visual zoological hallucinations (insects, small rodents, etc.), tactile hallucinations (most often in the form of a very realistic sensation of the presence of a foreign object - a thread or hair in the mouth), verbal hallucinations are possible, mainly of a threatening nature. Orientation in place and time is lost, but the person retains his or her own personality. Much less often, hallucinations occur in the form of large animals or fantastic monsters. Affective disorders are labile, fear, anxiety, confusion prevail.

At the height of delirious disorders, the patient is an interested spectator. Hallucinations are of a scene-like nature or reflect certain situations. They can be single or multiple, and are often colorless. As delirium tremens deepens, auditory, olfactory, thermal, tactile, and general sense hallucinations are added. According to various liters, hallucinatory phenomena are not simply varied, but complexly combined. Visual hallucinations in the form of a web, threads, wire, etc. are often encountered. Disorders of the body scheme are reduced to sensations of a change in the position of the body in space: surrounding objects begin to swing, fall, and spin. The sense of time changes; for the patient, it can shorten or lengthen. Behavior, affect, and delirious statements correspond to the content of hallucinations. Patients are fussy and have difficulty staying in place. Due to the prevailing affect of fear, patients try to run away, drive away, hide, shake things off, knock down or rob, address imaginary interlocutors. Speech in this case is abrupt, consists of short phrases or individual words. Attention becomes extremely distractible, mood is extremely changeable, facial expressions are expressive. Within a short time, bewilderment, complacency, surprise, despair replace each other, but fear is most often and most constantly present. With delirium, delirium is fragmentary and reflects hallucinatory disorders, in content here the delirium of persecution, physical destruction predominates, less often - jealousy, marital infidelity. Delusional disorders in delirium are not generalized, they are affectively saturated, specific, unstable, completely dependent on hallucinatory experiences.

Patients are highly suggestible. For example, if a patient is given a sheet of clean white paper and asked to read what is written, he sees the text on the sheet and tries to reproduce it (Reichardt's symptom); the patient starts a long conversation with the interlocutor if he is given a switched off telephone receiver or some other object called a telephone receiver (Aschaffenburg's symptom). When pressing on closed eyes and asking certain specific questions, the patient experiences corresponding visual hallucinations (Lillmann's symptom). It should be borne in mind that signs of increased suggestibility occur not only at the height of psychosis, but also at the very beginning of its development, and at its end, when acute symptoms are reduced. For example, persistent visual hallucinations can be induced in a patient after the end of delirium, if he is forced to peer at shiny objects (Bekhterev's symptom).

Another interesting point: the symptoms of psychosis can weaken under the influence of external factors - distractions (conversations with a doctor, medical staff). The symptom of awakening is typical.

In stage III of typical delirium tremens, lucid intervals can be observed, and patients experience significant asthenic symptoms. In the evening and at night, hallucinatory and delusional disorders become more pronounced, and psychomotor agitation increases. Anxiety can reach the level of raptus. By morning, the described condition turns into soporous sleep.

This is where the development of delirium tremens ends in most cases. The exit from psychosis is usually critical - after a deep, prolonged sleep, but it can be lytic - gradual; symptoms can be reduced in waves, with alternating weakening and renewal of psychopathological symptoms, but at a less intense level.

The patient's memories of the mental disorder he experienced are fragmentary. He can remember (often in great detail) the content of painful experiences, hallucinations, but he does not remember and cannot reproduce what was happening around him in reality, his behavior. All this is subject to partial or complete amnesia.

The end of delirium tremens is accompanied by intensely expressed emotional-hyperesthetic weakness. The mood is changeable: alternation of tearfulness, depression, elements of weakness with causeless sentimental contentment and rapture are observed; asthenic reactions are obligatory. 

After the clinical picture of delirium has been reduced, transitional syndromes are observed in some cases. These include residual delirium (an uncritical attitude towards the experience or individual delusional ideas), mild hypomanic (more common in men), as well as depressive, subdepressive or asthenodepressive states (more common in women).

Structural and dynamic characteristics of the thought process are partially and іmenї, but expressed incoherence, disintegration of thinking are not observed. After exiting the psychotic state, slowing down, small product of notes. thinking is noted, but it is always quite consistent, coherent. Manifestations of a peculiar alcoholic reasoning, alcoholic humor are possible

The course of delirium tremens is usually continuous (in 90% of cases), but can be intermittent: 2-3 attacks are observed, separated by light intervals lasting up to a day.

The duration of alcoholic delirium is on average from 2 to 8 days, in a small percentage of cases (up to 5) delirium can last up to days.

Mixed forms of delirium tremens

Alcohol delirium may become structurally more complicated: delusional experiences may be added, ideas of self-accusation, damage, attitude, persecution may appear. Hallucinations may become more complex, scene-like (everyday, professional, less often religious, battle or fantastic). In such cases, it is permissible to talk about mixed forms of delirium tremens, among which are systematized delirium and delirium with pronounced verbal hallucinations. These forms are not distinguished in ICD-10.

Systematized delirium tremens

The development of stages I and II does not differ from the course of typical delirium tremens. At stage III, multiple scene-like visual hallucinations begin to predominate in the clinical picture. The content is dominated by scenes of persecution, with the patient always being the object of an attempt and pursuit. The patient's behavior is dictated by the experiences he experiences: he tries to run away, hide, find a safe place to hide from his pursuers. The affect of fear is pronounced, constant, and persistent. Less common are visual hallucinations with a predominance of public spectacles or erotic scenes, witnessed by the patient. Some authors emphasize the constancy of drinking scenes. In such cases, the affect of surprise and curiosity predominates. Visual hallucinations coexist with various illusions, pareidolia, false recognition, false, constantly changing orientation in the surrounding environment. In this case, we are talking about the development of visual hallucinosis in the structure of alcoholic delirium.

Delusional statements are interconnected with the content of hallucinations, are of a stating nature and change depending on the change in hallucinations. Harm, due to the consistency of the story and "delusional details", resembles a systematized one.

Clouding of consciousness does not reach a deep level, since the patient, when coming out of the painful state, is able to reproduce the content of painful experiences. Vegetative and neurological disorders are not deep. Duration of psychosis is several days to a week or more. If the course of psychosis has acquired a princess character, then the exit is always logical, with residual delirium.

Delirium tremens with pronounced verbal hallucinations

In this case, we are talking about the development of verbal hallucinosis in the structure of delirium. Along with the characteristic intense visual, thermal, tactile hallucinations, body scheme disorders, visual illusions, there are constant verbal hallucinations. The content of hallucinations is similar to other types of delirium tremens, usually of a frightening nature. That is why the affect is determined mainly by anxiety, tension, fear. Delusional statements resemble those in systematized delirium. However, in this case it should be noted: delusional statements are not supported by arguments, so there is no need to talk about systematized delirium. In addition, signs of figurative delirium are revealed - confusion, ideas of delusional staging, a symptom of a positive double, spreading to many people. Orientation in place and time is slightly disturbed: the depth of clouding of consciousness, despite the abundance of productive disorders, is insignificant. Neurological and vegetative disorders are also not expressed. The duration of psychosis is from several days to several weeks. In the latter case, the painful disorders disappear gradually, with residual delirium.

Severe delirium tremens

The allocation of a group of severe delirium tremens is associated with pronounced somatovegetative and neurological disorders, features of psychopathological disorders, as well as the possibility of a fatal outcome. Severe delirium usually occurs with alcoholism of stage II-III or III with the preservation of high tolerance and a constant form of alcohol consumption. The development of severe delirium is often preceded by convulsions. There are two forms of severe delirium - professional and muttering.

Professional delirium tremens (delirium with professional delusions) F10.43*

Psychosis may begin with typical disorders, subsequently a transformation of the clinical picture is observed, as a rule, its aggravation. In this case, the intensity of hallucinatory phenomena decreases, persecution delusions weaken or disappear. Affective disorders become monotonous. Movement disorders and the patient's behavior also change. Instead of actions that are different in content, well-coordinated, requiring dexterity, strength, significant space, monotonous movements of a limited scale and stereotypical nature begin to prevail. Patients perform actions that are familiar to them, including professional ones: dressing and undressing, counting money, signing papers, washing dishes, ironing, etc. Distraction by external stimuli in this state gradually decreases, and may later disappear completely. In the initial period of delirium with professional delirium, variable false recognition of surrounding people and constantly changing false orientation in the environment are observed. Awareness of one's own personality is always preserved. As the condition worsens, false recognitions disappear, movements become increasingly automated. Symptoms of stunning occur during the day, which also indicates a worsening condition.

Professional delirium tremens is usually accompanied by complete amnesia. Less often, individual memories related to the onset of psychosis are preserved in the memory. When the condition worsens, professional delirium can turn into muttering; transitional states in the form of transient dysmnestic, Korsakov's syndrome or pseudoparalysis can also occur.

Muttering delirium tremens (delirium with muttering) F10.42*

Usually occurs after professional delirium, less often - after other forms of delirium tremens with their autochthonous unfavorable course or the addition of intercurrent diseases. Mussifying delirium tremens can develop very quickly, within a few hours or days, practically without hallucinatory-delusional experiences. This condition is characterized by a combination of deep clouding of consciousness, specific disorders of the motor sphere and pronounced somatoneurological disorders. Motor excitation is observed in most residents, it is limited to rudimentary movements of grasping, pulling, smoothing, picking (carphology). Myoclonic twitching of different muscle groups, choreiform hyperkinesis are often noted. Speech excitation - a set of simple, short words, syllables, interjections; the voice is quiet, devoid of modulations. Symptoms of stunning increase with the severity of the condition, they occur at night and during the day. Recovery is possible, after which the entire period of psychosis is amnestic.

It should be noted that in case of muttering delirium tremens, neurological and autonomic disorders may occupy a leading place in the clinical picture. It is accompanied by tachycardia, sharp changes in blood pressure, more often its decrease up to the development of collapse states, muffled heart sounds, hyperhidrosis, development of oliguria up to anuria (an unfavorable clinical symptom); subcutaneous hematomas often occur (capillary fragility, blood clotting disorder); hyperthermia (up to 40-41 °C), tachypnea, shallow, intermittent breathing are observed. Neurological symptoms are represented by ataxia, tremor, hyperkinesis, symptoms of oral automatism, muscle tone disorders, rigidity of the occipital muscles; urinary and fecal incontinence is possible (an unfavorable clinical sign).

As the clinical picture worsens, amentia-like disorders, speech and motor incoherence appear.

Atypical delirium tremens

Atypical forms of delirium tremens include psychotic states with the presence of disorders in the clinical picture characteristic of the endogenous process (schizophrenia). In these cases, symptoms characteristic of delirium tremens coexist with symptoms of mental automatism or are accompanied by oneiroid clouding of consciousness. Atypical delirium tremens often occurs after repeated psychoses. Similar clinical forms are not identified in ICD-10 as outlined syndromes; in this case, it is justified to classify such conditions as withdrawal syndrome with other delirium (F10.48*).

Delirium tremens with fantastic content (fantastic delirium, alcoholic oneiroid, oneiroid delirium)

The prodromal period is characterized by multiple photopsies, akoasmas, elementary visual hallucinations, and episodes of figurative delirium. The development of alcoholic oneiroid occurs as a complication of the clinical picture. Psychosis can begin as a fantastic hypnagogic or classic delirium. Visual and verbal hallucinations, figurative delirium, and delusional disorientation may occur during the day. Lucid intervals are characteristic. On the 2nd or 3rd day, usually at night, the clinical picture becomes more complicated: scene-like visual and verbal hallucinations occur, delusional disorders of fantastic content are observed, multiple false recognitions occur, motor excitation from complex coordinated actions becomes disordered and chaotic.

The content of the hallucinations experienced is often fantastic in nature, with terrifying visions of war, catastrophe, travel to exotic countries. In the minds of patients, everyday and adventure-fantastic events are bizarrely intertwined, without any specific sequence. Hallucinatory pictures are usually fragmentary, unfinished. Another interesting observation: with open eyes, the patient is a spectator, with closed eyes - a participant in the events taking place. At the same time, patients always have a feeling of rapid movement in space.

With prevalence of scene-like visual hallucinations in the clinical picture, general drowsiness and immobility increase; the condition resembles substupor or stupor. However, being in a state of inhibition, the patient answers questions, but only after multiple repetitions, in monosyllables. As with other types of delirium, autopsychic orientation is preserved, orientation in place and time is false. Double orientation is often observed - the coexistence of correct and false ideas. The patient's facial expressions resemble those of oneiroid - a frozen facial expression turns into a frightened, worried, surprised one. In the initial stages of psychosis, the affect of fear prevails. With further complication of the clinical picture, fear disappears, replaced by curiosity, surprise, close to complacency. Periodically, the patient tries to go somewhere, but calms down with persuasion or minor coercion. Negativism is absent.

The duration of psychosis is from several days to a week, the exit is critical, after a deep, long sleep. Painful memories remain for a long time, the patient talks about them in detail even after a long period. After psychosis, in some cases, residual delirium remains.

[ 1 ], [ 2 ]

Delirium tremens with oneiric disorders (alcoholic oneirism)

Delirium tremens with oneiric disorders is characterized by a small depth of clouding of consciousness, a significantly lesser expression of the illusory-delusional component compared to oneiroid delirium. From the very beginning, hallucinations are vivid. According to various authors, with onirism there are no pseudo-hallucinations of ordinary content, mental automatisms are not expressed. Psychosis ends critically, after deep sleep, on the 6th-7th day from its onset.

Delirium tremens with mental automatisms

Mental automatisms occur when typical delirium becomes more complicated or when systematized delirium is at its peak, when delirium is combined with pronounced verbal hallucinations or in oneiroid states. Mental automatisms are transient, incomplete, and almost all of their variants are observed - ideational, sensory, and motor. Automatisms most often occur in isolation, sometimes in combination (ideational with sensory or motor with sensory); however, according to many authors, three types of automatisms are never encountered simultaneously. When delirium is reduced, automatisms disappear first. The duration of psychosis varies up to 1.5-2 weeks. The exit is critical, with the lytic variant, residual delirium may form.

Differential diagnosis of delirium tremens

It is necessary to conduct differential diagnostics of alcoholic delirium and delirious disorders that arise as a result of acute intoxication with drugs with an anticholinergic effect (atropine, diphenhydramine, etc.), stimulants (cocaine, zphedrine, etc.), volatile organic substances, in infectious diseases, surgical pathology (acute pancreatitis, peritonitis), and fever of various origins.

Differential diagnostics of alcohol and intoxication delirium tremens

	Delirium tremens in alcohol addiction	Delirium tremens in case of intoxication
Anamnesis	Long-term systematic alcohol abuse, signs of alcohol dependence	Epidemiological history Data on the prodrome of infectious disease Surgical pathology Abuse of psychoactive substances (stimulants, volatile organic compounds, anticholinergics)
Clinical data	Absence of signs: acute intoxication with psychoactive substances; infectious disease; surgical pathology; fevers	Signs of intoxication with psychoactive substances Infectious disease Acute surgical pathology High temperature
Laboratory data	Signs of alcoholic liver damage (increased liver enzyme levels), chronic intoxication (increased ESR, relative leukocytosis)	Determination of psychoactive substances in biological environments Identification of an infectious agent Signs of surgical pathology (eg, high amylase levels in acute pancreatitis)

If problems arise with the diagnosis of a delirious state, the help of an infectious disease specialist or surgeon may be necessary.

[ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 9 ], [ 10 ]

Treatment of delirium tremens and alcoholic encephalopathy (F10.40*)

Modern tactics of treating delirium tremens, regardless of its severity, are aimed at reducing intoxication of the body, maintaining vital functions or preventing their disorders. Already with the development of early signs of delirium, plasmapheresis is prescribed with the removal of 20-30% of the circulating plasma volume. Then infusion therapy is carried out. Such tactics can significantly alleviate the course of psychosis, and in some cases prevent its further development. The method of choice for detoxification therapy in typical delirium tremens is forced diuresis: massive infusions of solutions in a volume of 40-50 mg / kg under the control of central venous pressure, electrolyte balance, acid-base balance of the blood, plasma glucose and diuresis; if necessary, diuretics and insulin are prescribed. Enterosorbents are also used as part of detoxification therapy.

It is necessary to replenish electrolyte losses and correct the acid-base balance. Potassium loss is especially dangerous, as it can cause tachyarrhythmia and cardiac arrest. In case of potassium deficiency and metabolic alkalosis, 1% potassium chloride solution is administered intravenously slowly, no more than 150 ml/day. In case of renal dysfunction, potassium preparations are contraindicated in each clinical situation; doses are set depending on the indications of water-electrolyte balance and acid-base balance. To eliminate metabolic acidosis, buffer solutions containing so-called metabolizable anions of organic acids (acetate, citrate, malate, gluconate) are used, for example, sterofundin, acesol and other solutions intravenously slowly under the control of acid-base balance.

Large doses of vitamins (thiamine - up to 1 g/day, pyridoxine, ascorbic and nicotinic acids) are added to solutions for intravenous infusion.

Prescribed drugs that enhance metabolism (1.5% solution of meglumine sodium succinate 400-800 ml intravenously by drip 4-4.5 ml/min for 2-3 days or cytoflavin 20 40 ml in 200-400 ml of 5% glucose solution intravenously by drip 4-4.5 ml/min for 2-3 days).

Cytoflavin is the first complex neurometabolic drug developed on the basis of modern knowledge and discoveries in the field of molecular biology of cellular respiration and clinical medicine.

Cytoflavin is a harmonious neuroprotective composition that promotes safe and rapid recovery from withdrawal.

After the first day of treatment, headaches, sweating, weakness, and irritability disappear. After the course of therapy, sleep is normalized, affective disorders are reduced. Cytoflavin is well tolerated and safe.

• Composition: 1 ml of the preparation contains: succinic acid - 100 mg, nicotinamide - 10 mg, riboxin - 20 mg, riboflavin - 2 mg.
• Indications: toxic (including alcoholic) encephalopathy, alcohol withdrawal syndrome.
• Contraindications: individual intolerance to the components of the drug.
• Method of administration and dosage: 10 ml of solution intravenously by drip diluted in 200 ml of glucose 2 times a day for 5 days.
• Packaging: ampoules with injection solution No. 10, No. 5.

Also required are agents that improve the rheological properties of the blood (dextran (rheopolyglucin) 200-400 ml/day], cerebral circulation (instenon solution 2 ml 1-2 times a day or 2% pentoxifylline solution 5 ml in 5% glucose solution 1-2 times a day). Nootropic drugs that do not stimulate the central nervous system are used [semax - 0.1% solution 2-4 drops and nose 2 times a day or hopantenic acid (pantogam) 0.5 g 3 times a day), and hepatoprotectors |ademetionine (heptral) 400 mg 1-2 times a day, thioctic acid (espa-lipon) 600 mg 1 time per day|. Medicines and measures aimed at preventing hypoxia and cerebral edema are also indicated: 10% meldonium (mildronate) solution, 10 ml once a day or 5% mexidol solution, 2 ml 2-3 times a day. 25% magnesium sulfate solution, 10 ml 2 times a day, oxygen therapy, hyperbaric oxygenation, cranial hypothermia, etc. Careful monitoring of the patient's vital functions (breathing, cardiac activity, diuresis) and timely symptomatic therapy aimed at maintaining them (for example, prescribing cardiac glycosides for heart failure, analeptics for respiratory failure, etc.) are necessary. A specific choice of drugs and solutions for infusion, drug and non-drug therapy should be based on the disorders present in each specific case.

Treatment of delirium tremens and acute encephalopathy

States	Recommended treatment
Predelirium, prodromal period of acute alcoholic encephalopathy	Treatment aimed at reducing intoxication, correcting electrolyte disturbances and improving blood rheology: plasmapheresis (20-30% of circulating plasma volume); povidone 5 g 3 times a day orally diluted with water; isotonic sterofundin 500 ml, or disol 400 ml; 1% solution of potassium chloride 100-150 ml, intravenously by drip (with hypokalemia, adequate diuresis); dextran rheopolyglucin) 200-400 ml intravenously by drip
	Treatment aimed at relieving psychomotor agitation and sleep disorders: 0.5% diazepam solution, 2-4 ml intramuscularly or intravenously by drip up to 0.08 g/day; 0.1% phenazepam solution, 1-4 ml intramuscularly and intravenously by drip up to 0.01 g/day
	Vitamin therapy: 5% thiamine solution (vitamin B1), 4 ml intramuscularly; 5% pyridoxine solution (vitamin B6), 4 ml intramuscularly; 1% nicotinic acid solution (vitamin PP), 2 ml intramuscularly; 5% ascorbic acid solution (vitamin C), 5 ml intravenously; 0.01% cyanocobalamin solution (vitamin B12), 2 ml intramuscularly.
	Neurometabolic therapy: Semax - 0.1% solution 2-4 drops in the nose 2 times a day or hopantenic acid 0.5 g 3 times a day
	Hepatoprotectors: ademetionine 400 mg T-2 times a day; thioctic acid (espa-lipon) 600 mg 1 time per day
Full blown delirium tremens, acute alcoholic encephalopathy	Fixation of the patient
	Infusion therapy in the volume of 40-50 ml/kg under the control of central venous pressure, electrolyte balance, acid-base balance of the blood, blood plasma glucose and diuresis, if necessary, prescribe diuretics, insulin. Use 1.5% solution of meglumine sodium succinate (reamberin) 400-500 ml intravenously by drip at a rate of 4-4.5 ml/min for 2-3 days or cytoflavin 20-40 ml in 200-400 ml of 5% glucose solution intravenously by drip at a rate of 4-4.5 ml/min for 2-3 days, dextran (rheopolyglucin) 200-400 ml/day, sterofundin, acesol disol
	Prevention of hypoxia and cerebral edema; 10% solution of medonium, 10 ml once a day or 5% solution of mexidol, 2 ml 2-3 times a day, 25% solution of magnesium sulfate, 10 ml 2 times a day
	In case of uncontrollable excitement, convulsive states - short-acting barbiturates (sodium thiopental, texobarbital (hexenal) up to 1 g/day intravenously by drip under constant monitoring of breathing and blood circulation)
	Oxygen therapy or hypertensive oxygen therapy
	Symptomatic treatment of somatic complications
Severe forms of delirium tremens, Wernicke encephalopathy.	Monitoring of vital functions (respiration, heart rate, diuresis), regular control of acid-base balance, determination of concentrations of potassium, sodium, glucose in blood plasma
	Balanced infusion therapy
	Cranial hypothermia
	Nootropic agents: piracetam 5-20 ml of 20% solution intravenously, cortexin 10 mg intramuscularly in 1 ml of 0.9% sodium chloride solution
	Vitamin therapy
	Hyperbaric oxygenation course
	Symptomatic treatment of somatic complications

It should be noted that the antipsychotic activity of existing psychotropic drugs in delirium tremens has not been proven. They are prescribed for psychomotor agitation, severe anxiety and insomnia, as well as in the presence and history of convulsions. The drugs of choice are benzodiazepine drugs: 0.5% diazepam solution (Relanium), 2-4 ml intramuscularly or intravenously by drip up to 0.06 g / day; 0.1% phenazepam solution, 1-4 ml intramuscularly or intravenously by drip up to 0.01 g / day and short-acting barbiturates sodium thiopental, hexobarbital (hexenal) up to 1 g / day intravenously by drip under constant monitoring of breathing and circulation. In severe delirium tremens (professional, mussifying) and acute alcoholic encephalopathy, the administration of psychotropic drugs is contraindicated.