Alcohol withdrawal: workup and management

Alcohol withdrawal begins 6–24 hours after the last drink. Seizures peak at 12–48 hours and delirium tremens at 48–96 hours. Assess severity and risk (CIWA-Ar, PAWSS), treat with symptom-triggered benzodiazepines or phenobarbital, give thiamine before glucose, and look for coexisting illness.

Working diagnosis Adult · US guidelines Draft · awaiting physician review

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01Orient

What's new in the evidence

ASAM 2020 guideline still applies; phenobarbital use has grown
Phenobarbital 10 mg/kg IV with lorazepam in the ED reduced ICU admission (RCT); hospital-wide protocols commonly load 10–15 mg/kg IV
Target-trial emulation (2026): phenobarbital outcomes were similar to diazepam
Start relapse-prevention medication before discharge

Differential diagnoses

Alcohol withdrawal, uncomplicated
Delirium tremens (can't miss)
Wernicke encephalopathy (can't miss)
Sepsis, meningitis or pneumonia presenting as agitation (can't miss)
Intracranial hemorrhage after a fall (can't miss)
Hypoglycemia, hyponatremia, hepatic encephalopathy
Benzodiazepine withdrawal, stimulant intoxication, thyrotoxicosis

02Assess

Risk scores and decision tools

CIWA-Ar (for communicative patients)
PAWSS (≥4 = high risk of complicated withdrawal)
RASS when delirium makes CIWA-Ar unusable

Key history questions

Time and amount of last drink; daily intake
Previous withdrawal, withdrawal seizures or delirium tremens
Other substances, especially benzodiazepines, opioids, stimulants
Falls, head injury, recent illness
Liver disease, prior admissions
Readiness to change drinking

Examination findings

Tremor, sweating, tachycardia, hypertension, fever
Agitation, hallucinations, disorientation
Ophthalmoplegia, nystagmus, ataxia (Wernicke)
Signs of liver disease, head injury, infection

03Investigate

Initial investigations

CIWA-Ar score and PAWSS risk score
Glucose, BMP, magnesium, phosphate
CBC, LFTs, INR, lipase
Blood alcohol level and urine drug screen
ECG

Advanced investigations

CT head if trauma, focal signs, first seizure or atypical course
Lumbar puncture if fever with altered mental status
Chest X-ray if aspiration risk

04Treat

Immediate management

Thiamine 100–500 mg IV before glucose; 500 mg IV three times daily if Wernicke suspected
Symptom-triggered benzodiazepine per CIWA-Ar (lorazepam, diazepam or chlordiazepoxide per protocol)
Withdrawal seizure: IV benzodiazepine (lorazepam 2–4 mg)
Correct glucose, potassium, magnesium and phosphate

First-line treatment

Lorazepam preferred in advanced liver disease or older adults
Phenobarbital per institutional protocol (often 10–15 mg/kg IV ideal body weight load) as an alternative or adjunct, with monitoring
Folate and multivitamin; IV fluids if dehydrated

Second-line treatment

Refractory withdrawal (escalating benzodiazepine needs): phenobarbital, ICU, consider dexmedetomidine as adjunct
Avoid antipsychotics as monotherapy; they lower seizure threshold

Specialist referrals

Addiction medicine or consult-liaison psychiatry
ICU for delirium tremens or refractory withdrawal

05Disposition

Admission criteria

History of withdrawal seizures or delirium tremens
PAWSS ≥4 or CIWA-Ar persistently ≥15
Concurrent illness, pregnancy or unsafe home
Hallucinations or delirium

Safe discharge criteria

Mild withdrawal (CIWA-Ar <10) without high-risk history
Reliable support and follow-up
Addiction treatment plan arranged

Follow-up timing

Addiction treatment follow-up within 1 week

Patient instructions

Do not stop drinking abruptly at home without a medical plan if you have had seizures or DTs
Return for confusion, hallucinations or seizures

Monitoring

CIWA-Ar every 1–4 hours depending on score
Sedation scale, vital signs, respiratory status

Clinical pearls and pitfalls

Start relapse-prevention medication before discharge: naltrexone (avoid in decompensated liver disease or opioid use), acamprosate (renal dosing) or others
CIWA-Ar needs a patient who can communicate; use a sedation-based scale in delirium
Withdrawal can occur with a positive blood alcohol level

RefGuidelines and landmark evidence

For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.