Alcohol Intoxication and Withdrawal Spectrum

Key considerations: Subdural hematoma (alcoholics fall and have coagulopathy), Wernicke encephalopathy, Hypoglycemia

Cannot miss

history: Last drink, daily intake quantity, prior withdrawal history (seizures, DTs), concurrent drug use, social support; exam: CIWA-Ar scoring, tremor, diaphoresis, vital signs, neurologic exam (focal findings), mental status; labs: Blood alcohol level, glucose, BMP (anion gap for toxic alcohols), LFTs, CBC (thrombocytopenia, macrocytosis), coags, thiamine level, osmolar gap; imaging: Head CT if trauma, fall, focal findings, or first seizure; bedside: CIWA-Ar scoring, POC glucose

immediate: Thiamine 100mg IV BEFORE glucose; Intoxication: supportive, aspiration precautions; general: Withdrawal: CIWA-Ar guided benzodiazepine therapy (lorazepam or diazepam); Severe/DTs: ICU, high-dose benzodiazepines, phenobarbital for refractory cases; All patients: folate, multivitamin, magnesium replacement; Seizure prophylaxis with benzodiazepines (NOT phenytoin)

admit: CIWA >=8, prior seizures or DTs, concurrent medical illness; discharge: Mild withdrawal (CIWA <8) with social support and outpatient follow-up; consults: Addiction medicine, social work, psychiatry

Symptom-triggered CIWA-Ar guided dosing is superior to fixed-dose schedules — less total benzodiazepine use and shorter stays
Phenytoin does NOT prevent or treat alcohol withdrawal seizures — only benzodiazepines work
DT onset: typically 48-96 hours after last drink, mortality 5-15% without treatment