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
- Risk-stratify and pick protocol; administer benzodiazepines early and adequately.
- Escalate with phenobarbital or ICU sedatives if refractory; manage airway and autonomic instability.
- Give thiamine before glucose; correct electrolytes; arrange addiction treatment and relapse prevention.
Clinical Synopsis & Reasoning
Autonomic hyperactivity, agitation, hallucinations, and seizures peak at 48–72 hours after cessation. Use symptom-triggered or front-loaded benzodiazepines; consider adjunct phenobarbital or dexmedetomidine/propofol in ICU. Give high-dose IV thiamine before glucose to prevent Wernicke's.
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 |
|---|
| CIWA-Ar or RASS-based protocol | Monitoring | Dose to symptom target | — |
| BMP/Mg/Phos and EKG | Safety | Electrolyte derangements, QTc | Replete aggressively |
| Infection/trauma screen | Differential | Mimics/precipitants | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Delirium tremens (agitation, hallucinations, autonomic instability) | High mortality | ICU; benzodiazepine/phenobarbital protocol |
| Withdrawal seizures | Complication | Escalate sedation; airway protection |
| Wernicke encephalopathy risk | Neurologic injury | High-dose IV thiamine before glucose |
| Hepatic failure or respiratory disease | Sedation risk | Lower thresholds for ICU, careful dosing |
| Polysubstance use | Complex course | Toxicology input |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Diazepam/lorazepam front-loading or symptom-triggered | GABA-A potentiation | Minutes | Core therapy | Adjust for liver disease |
| Phenobarbital (adjunct or monotherapy protocol) | Barbiturate | Minutes-hours | Refractory cases | Monitor respiratory status |
| Thiamine 200–500 mg IV before glucose; folate/multivitamins | Nutritional | Hours | Prevent/treat Wernicke | — |
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/critical care guidance on alcohol withdrawal — Link