Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Identify high‑risk AWS (PAWSS) and begin frequent monitoring (CIWA/RASS).
- Front‑load benzodiazepines or use symptom‑triggered dosing; escalate rapidly in DTs.
- Add phenobarbital for refractory symptoms; intubate if needed for airway and sedation with propofol.
- Administer thiamine before glucose; replace Mg/K/PO4; manage fluids and nutrition.
- Treat concurrent issues (infection, pancreatitis, trauma); plan relapse prevention and addiction follow‑up.
Clinical Synopsis & Reasoning
High‑risk patients with autonomic instability, hallucinations, agitation, or seizures need aggressive benzodiazepine therapy (symptom‑triggered or front‑loaded), early phenobarbital adjunct in refractory cases, thiamine before glucose, electrolyte repletion, and ICU monitoring.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Risk tools (PAWSS) and monitoring scales (CIWA‑Ar or RASS) | Stratification/monitoring | High scores predict complicated AWS | Choose scale suitable for ICU |
| Electrolytes, Mg, glucose, LFTs | Complications | HypoMg/K, hypoglycemia, hepatic issues | Serial checks |
| ECG and vitals | Safety | Arrhythmias, QT risk | Telemetry in severe cases |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Diazepam or Lorazepam high‑dose protocols | GABA‑A agonists | Minutes | First‑line for AWS/DTs | Front‑load strategy reduces ICU admissions |
| Phenobarbital 130–260 mg IV boluses (up to ~10–15 mg/kg cumulative) | Barbiturate | Hours | Adjunct or monotherapy protocol | Respiratory depression risk |
| Thiamine 200–500 mg IV before glucose | Vitamin | Hours | Prevent/treat Wernicke’s | Give before dextrose |
| Dexmedetomidine/Propofol (adjuncts) | Sedatives | Minutes | Control autonomic surge/intubated pts | Do not replace GABA therapy |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- ASAM Clinical Practice Guideline on Alcohol Withdrawal Management — Link