Alcohol Withdrawal

Key considerations: Delirium tremens, Withdrawal seizures, Wernicke encephalopathy

Cannot miss

history: Last drink, daily intake, prior withdrawal history (seizures, DT), concurrent drug use; exam: Tremor, diaphoresis, tachycardia, hypertension, mental status, look for co-morbidities; labs: BMP (Mg, phos), CBC, LFTs, lipase, ethanol level, UA, blood cultures if febrile; imaging: CT head if AMS, seizure (especially first seizure), or focal findings; bedside: CIWA-Ar scoring

immediate: Benzodiazepines: diazepam 10-20mg IV or lorazepam 2-4mg IV, repeat as needed; Thiamine 500mg IV BEFORE glucose (prevent Wernicke); IV fluids, electrolyte repletion (Mg, K, phos); general: CIWA-Ar protocol: symptom-triggered dosing is superior to fixed-schedule; Phenobarbital 130-260mg IV for severe/refractory withdrawal; Folate, multivitamin; Seizure prophylaxis: benzodiazepines (NOT phenytoin — ineffective for alcohol withdrawal seizures)

admit: CIWA >15, history of DT or withdrawal seizures, concurrent medical illness; ICU for DT or refractory withdrawal; discharge: Mild withdrawal (CIWA <10) after observation with outpatient detox plan; consults: Addiction medicine, social work, psychiatry

Phenytoin does NOT prevent or treat alcohol withdrawal seizures — only benzodiazepines work
Thiamine BEFORE glucose — glucose metabolism consumes thiamine and can precipitate Wernicke
DT typically occurs 48-96hr after last drink and has 5% mortality even with treatment
CIWA >20 = severe withdrawal — consider ICU level care