Alcohol withdrawal

Clinical Presentation

• 6 to 12 hours after last drink: shaking, headache, sweating, anxiety, nausea, or vomiting
• 12 to 24 hours after last drink: confusion, hallucinosis (with awareness of reality), tremor, or agitation
• 24 to 48 hours after last drink: seizures
• 48 hours after last drink: delirium tremens, high blood pressure, and fever
  • Can persist anywhere from 4 to 12 days

Risk Factors

• Severity predicted by PAWSS scale: if score ≤3 can manage as outpatient
• History of alcohol withdrawal, especially if previously severe (e.g. delirium tremens)
• Age
• Alcohol tolerance
• Concurrent sedative medications
• Major medical comorbidities
• Drinking all day long

Investigations

• Monitor electrolytes and extended electrolytes for refeeding syndrome

Management

• If history of seizures: diazepam 20mg q1h x3 doses before starting CIWA
• Start CIWA-Ar (Clinical Institute Withdrawal Assessment - Alcohol revised) q1h
  • CIWA-Ar 10-20
    • First-line: diazepam 10mg PO/IV q1h
    • Liver dysfunction: lorazepam 2mg PO/IV/IM q1h
    • Liver failure, age >60, chronic opioid use, acute respiratory illness: lorazepam 1mg PO/IV/IM q1h
  • CIWA-Ar >20
    • 1L NS bolus over 30 minutes followed by 200mL/h
    • First-line: diazepam 20mg PO/IV q1h
    • Liver dysfunction: lorazepam 4mg PO/IV/IM q1h
    • Liver failure, age >60, chronic opioid use, acute respiratory illness: lorazepam 2mg PO/IV/IM q1h
  • Discontinue CIWA-Ar protocol after two consecutive scores <10
• For seizures:
  • Lorazepam prn until terminates
  • After seizure, lorazepam 2mg IV once to prevent recurrence
• Alternatives to diazepam/lorazepam:
  • Chlordiazepoxide
  • Phenobarbital
    • Load 10mg/kg IV up front over 30min (if has not received significant benzos)
    • Then give 130-260mg IV prn for mild to severe withdrawal symptoms
    • Titrate to effect; there is no maximum dose
    • Maintenance with 100-200mg PO/IM q1h prn
• Thiamine
  • Standard: 250mg IM/IV q24h x3d
  • High-dose: 500mg IV TID x3