⚠️ Alcohol withdrawal and delirium tremens (DTs) can be life-threatening. Symptoms often begin within hours of stopping or reducing heavy alcohol intake; seizures commonly occur within the first 24-48 hours and DTs classically develop around 48-72 hours. Always ask when the last drink was taken, assess risk, give thiamine where indicated, and treat withdrawal with a benzodiazepine protocol. Teaching point: The key NICE-aligned priorities are benzodiazepine-based withdrawal treatment, thiamine for Wernicke’s prevention/treatment, and recognising severe withdrawal early. DTs are not treated by “sedation only”: the patient also needs fluids, electrolytes, nutrition, thiamine, monitoring and assessment for other causes of delirium.

🚑 Acute Alcohol Withdrawal Management
ABC approach: BP, HR RR, Temp, IV fluids if dry, glucose, sepsis, agitation, electrolytes, seizures, consciousness. Always be ready to investigate alternative causes of confusion, head injury, infection, hypoglycaemia, hepatic encephalopathy or intracranial pathology Escalate early to senior/ICU support if severe agitation, seizures, hypoxia, hypotension, tachycardia, severe DTs or significant comorbidity, risk of hypoventilation with sedation. Thiamine: Give IV before glucose if Wernicke’s risk or suspected Wernicke’s encephalopathy. Benzodiazepines: Chlordiazepoxide or diazepam; consider Lorazepam in liver impairment or for withdrawal seizures/DTs. Use fixed-dose or symptom-triggered treatment if staff can monitor frequently and safely. Seizures: use Lorazepam; do not use phenytoin for alcohol withdrawal seizures. DTs: NICE recommends oral lorazepam first-line, If symptoms persist or oral medication is declined, use parenteral Lorazepam or Haloperidol with appropriate monitoring.

🚑 Acute Alcohol Withdrawal Management

ABC approach: BP, HR RR, Temp, IV fluids if dry, glucose, sepsis, agitation, electrolytes, seizures, consciousness. Always be ready to investigate alternative causes of confusion, head injury, infection, hypoglycaemia, hepatic encephalopathy or intracranial pathology
Escalate early to senior/ICU support if severe agitation, seizures, hypoxia, hypotension, tachycardia, severe DTs or significant comorbidity, risk of hypoventilation with sedation.
Thiamine: Give IV before glucose if Wernicke’s risk or suspected Wernicke’s encephalopathy.
Benzodiazepines: Chlordiazepoxide or diazepam; consider Lorazepam in liver impairment or for withdrawal seizures/DTs. Use fixed-dose or symptom-triggered treatment if staff can monitor frequently and safely.
Seizures: use Lorazepam; do not use phenytoin for alcohol withdrawal seizures.
DTs: NICE recommends oral lorazepam first-line, If symptoms persist or oral medication is declined, use parenteral Lorazepam or Haloperidol with appropriate monitoring.

📊 Alcohol Withdrawal Scales

CIWA-Ar can guide symptom-triggered benzodiazepine therapy in suitable settings.
CIWA-Ar maximum score = 67; most items are scored 0-7, orientation 0-4.
Use formal scoring only where staff are trained and observations can be repeated safely.

🧮 CIWA-Ar Interpretation

0-8: minimal/mild withdrawal.
9-14: mild to moderate withdrawal; consider medication depending on risk and protocol.
15-20: moderate withdrawal; treatment usually required.
>20: severe withdrawal; frequent reassessment, higher benzodiazepine requirements and possible HDU/ICU support.

📝 CIWA-Ar Items

Nausea and vomiting
Tremor
Paroxysmal sweats
Anxiety
Agitation
Tactile disturbances
Auditory disturbances
Visual disturbances
Headache
Orientation and clouding of sensorium

💡 Symptom-triggered therapy: benzodiazepine dosing is adjusted to withdrawal severity, usually using CIWA-Ar. This is appropriate only where staff can monitor frequently and safely; otherwise use a fixed-dose reducing regimen.

🧪 Neurochemistry

Alcohol enhances GABA activity and inhibits NMDA/glutamate activity.
Chronic alcohol exposure causes compensatory downregulation of inhibitory tone and upregulation of excitatory pathways.
Withdrawal produces autonomic hyperactivity, tremor, agitation, seizures and delirium due to unopposed excitatory neurotransmission.
Alcohol dependence is also associated with thiamine deficiency, risking Wernicke-Korsakoff syndrome.

💊 Management Details

Supportive care: calm, well-lit environment, fluids, nutrition, electrolyte correction, falls precautions and close observations.
Thiamine prophylaxis: offer oral thiamine to harmful/dependent drinkers at risk; use parenteral thiamine followed by oral thiamine if admitted/ED and malnourished, at risk of malnutrition or decompensated liver disease.
Suspected Wernicke’s encephalopathy: give parenteral thiamine for at least 5 days unless excluded, then oral thiamine.
Benzodiazepines: chlordiazepoxide or diazepam are preferred for standard assisted withdrawal protocols; Lorazepam is useful where rapid action is needed or liver impairment is a concern.
Older adults / liver impairment: use reduced doses and careful monitoring; consider lorazepam in liver impairment and avoid benzodiazepines in severe liver impairment where possible.
Antipsychotics: do not use as sole treatment for withdrawal. Haloperidol may be used for persistent DT symptoms/agitation when benzodiazepines are insufficient, with QT, seizure-threshold and Parkinsonism cautions.

⚡ Risk Factors for Severe Withdrawal

Previous withdrawal seizures or delirium tremens.
Very high alcohol intake, especially >30 units/day; consider inpatient withdrawal if >30 units/day or SADQ >30.
Regularly drinking 15-30 units/day plus significant physical/psychiatric comorbidity, malnutrition, cognitive impairment or poor social support.
Concurrent benzodiazepine dependence.
Older age, homelessness, frailty, liver disease, infection or acute medical illness.

🔍 Investigations

Bloods: FBC, U&E, LFT, clotting, CRP, glucose, calcium, magnesium, phosphate.
Consider blood alcohol level, toxicology, cultures, CXR, ECG or ABG/VBG depending on presentation.
CT head if head injury, focal neurology, seizure with trauma, persistent altered mental state or diagnostic uncertainty.
Always consider mimics: sepsis, hypoglycaemia, hepatic encephalopathy, intracranial bleed, Wernicke’s encephalopathy, drug intoxication or delirium.

📚 References

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Alcohol Withdrawal (Delirium Tremens)