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
- History of same
- Age
- Alcohol tolerance
- Concurrent sedative medications
- Major medical comorbidities
- Drinking all day long
Investigations
- Monitor electrolytes and extended electrolytes for refeeding syndrome
Management
- CIWA-Ar (Clinical Institute Withdrawal Assessment - Alcohol revised) q1h
- Discontinue CIWA-Ar after two consecutive scores <10
- 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
- If history of seizures:
- Diazepam 20mg q1h x3 doses before starting CIWA
- 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
