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Alcohol Withdrawal
Key considerations: Delirium tremens (DTs), Withdrawal seizures, Wernicke encephalopathy
Cannot miss
- Delirium tremens (DTs)
- Withdrawal seizures
- Wernicke encephalopathy
- Concurrent illness masked by withdrawal (SDH, infection, GI bleed)
Likely diagnoses
- Uncomplicated alcohol withdrawal
- Alcohol hallucinosis
- Withdrawal seizure
- Delirium tremens
Red flags
- Prior DTs or withdrawal seizures
- Prolonged heavy use
- Age >40
- Concurrent medical illness
- Vital sign instability
- Hallucinations
- Confusion/disorientation
Workup
- history: Quantity and duration of alcohol use; Time of last drink; Prior withdrawal episodes — seizures? DTs?; Other substance use; Medical comorbidities; exam: Vital signs (tachycardia, hypertension, fever); Tremor; Diaphoresis; Mental status; Stigmata of liver disease; labs: BMP (glucose, Mg, K, phosphate); CBC; Hepatic function panel; Lipase; Ethanol level; Urine drug screen; imaging: CT head if altered mental status, focal neuro signs, trauma history, or seizure; bedside: CIWA-Ar scoring; Fingerstick glucose
Management
- immediate: Thiamine 100mg IV (BEFORE glucose to prevent Wernicke); CIWA-Ar protocol for symptom-triggered benzodiazepine dosing; IV fluids; Correct electrolytes (Mg, K, phosphate); general: Benzodiazepines: chlordiazepoxide 25-100mg q1-2h or lorazepam 2-4mg q1-2h based on CIWA; Folate 1mg daily; Multivitamin; Banana bag (NS + MVI + thiamine + folate + Mg); specific: diagnosis: Withdrawal Seizure; steps: Benzodiazepine: lorazepam 2-4mg IV; Usually self-limited; NOT phenytoin (ineffective for withdrawal seizures); Assess for DTs risk — often precedes DTs by 24h; diagnosis: Delirium Tremens; steps: ICU admission; High-dose benzodiazepines (may need 100s of mg); If refractory: phenobarbital 130mg IV q15-20min or propofol drip; Intubation if unable to protect airway; diagnosis: Wernicke Encephalopathy; steps: Thiamine 500mg IV q8h for 3-5 days; Classic triad: encephalopathy, oculomotor dysfunction, ataxia (all 3 present in only 16%); Thiamine before glucose
Disposition
- admit: CIWA >15 despite treatment; Prior DTs or withdrawal seizures; Concurrent medical illness; Inadequate social support; discharge: CIWA <8 for several hours; Tolerating PO; Safe social situation; Outpatient detox referral; consults: Addiction medicine/psychiatry; Social work for rehab/detox placement
Clinical pearls
- Timeline: tremors 6-24h → seizures 12-48h → DTs 48-96h after last drink
- DTs mortality is 5-15% untreated; <1% with adequate benzodiazepine treatment
- Phenytoin is NOT effective for alcohol withdrawal seizures — use benzodiazepines
- Symptom-triggered protocol (CIWA-based) uses 50% less benzodiazepines than fixed dosing
Source and review
- ASAM Clinical Practice Guideline on Alcohol Withdrawal Management 2020. Last reviewed: 2024-11-01