Alcohol Withdrawal


last admission on Normally drinks
-- SX: anxiety, tremulousness,hallucinations, HA, palpitations, GI upset.
6–12 hrs->Tremors, Anxiety, irritability, HA, N/V, (↑HR, ↑BP, diaphoretic)
12–24 hours tremors, Hallucinations (visual), (↑HR, ↑BP, diaphoretic)
≤48 hrs Seizures window Still tremulous, agitated
≥48 hrs DT: disorientation, agitation, hallucinations, tachycardia, HTN, fever, diaphoresis
-- PE:anxious, agitated, tremulous, diaphoretic,tachycardia, confused/hallucinations
-- W/U: CBC,CMP,Mg, Phos, Etho level, UDS, EKG, CTH(AMS, Focal deficit)
-- MEDS:
-- DDX: consider AMS workup if in doubt

Plan

  • Mild–Moderate Alcohol Withdrawal order set applied

  • on CIWA protocal with CIWA protocol with lorazepam/diazepam

  • NPO (risk of aspiration) 

  • Trend Lytes, Mg, PO4 and replete

  • antacids (Maalox- quick onset) PRN for GI irritation

  • IVF as needed for dehydration

  • Seizure/Aspiration/Fall precautions

  • Thiamine and Multivitamin to Prevents Wernicke’s encephalopathy

  • Low–moderate risk → thiamine 200 mg IV daily ×3–5 days → 100 mg PO TID ×1–2 weeks.

  • High risk / suspected Wernicke’s (confusion, ataxia, ophthalmoplegia, malnutrition, chronic alcohol use) → thiamine 500 mg IV TID ×2 days → 250 mg IV/IM daily ×5 days → 100 mg PO daily on discharge.

  • Social work for substance use support

  • Dietitian for malnutrition risk

ICU

  • ICU electrolyte protocol, replete as needed

  • Phenobarb split (975 mg total) 390 mg now → 260 mg @ 3 hrs → 260 mg @ 6 hrs → 130 mg PRN/remainder

  • if ≥12 mg lorazepam equiv (≥24 diazepam) 260 mg now → reassess → 260 later we try to avoid Avoid full 10 mg/kg load (975 mg total)

  • If refractory to PRN benzos per CIWA

  • Consider adjunct Gabapentin 600 mg TID

  • Add dexmedetomidine (if not intubated): start 0.2–0.7 mcg/kg/hr IV infusion (can titrate up to ~1.5 mcg/kg/hr);

  • propofol infusion (if intubated): start 5–10 mcg/kg/min, titrate to effect (typical 5–50 mcg/kg/min)**

  • Ketamine (refractory cases): 0.3–0.5 mg/kg IV bolus, then 0.3–1 mg/kg/hr infusion

  • If agitation due to delirium → low-dose antipsychotics Olanzapine: 2.5–5 mg PO/IM PRN Check QTc (avoid if >500 ms)

  • ☐ CBC

  • ☐ CMP

  • ☐ Mg

  • ☐ Phos

  • ☐ EtOH level

  • ☐ UDS

  • ☐ EKG

  • ☐ CTH (if AMS or focal deficit)

  • ☐ CIWA protocol (lorazepam/diazepam)

  • ☐ Thiamine

    • ☐ Low risk: 200 mg IV daily ×3–5 days → PO

    • ☐ High risk: 500 mg IV TID ×2 days → taper

  • ☐ Multivitamin

  • ☐ IVF PRN

  • ☐ Electrolyte repletion (K, Mg, Phos)

  • ☐ Maalox PRN

  • ☐ NPO (aspiration risk)

  • ☐ Seizure precautions

  • ☐ Aspiration precautions

  • ☐ Fall precautions

  • ☐ Telemetry

  • ☐ CIWA scoring

  • ☐ Trend labs (BMP, Mg, Phos)

  • ☐ Social work (SUD)

  • ☐ Dietitian

  • If Escalation / ICU

  • ☐ Phenobarb protocol ((975 mg total) 390 mg now → 260 mg @ 3 hrs → 260 mg @ 6 hrs → 130 mg PRN/remainder

  • ☐ Gabapentin 600 mg TID

  • ☐ Dexmedetomidine (if not intubated)

  • ☐ Propofol (if intubated)

  • ☐ Ketamine (refractory)

  • ☐ Olanzapine PRN (check QTc)

  • ☐ ICU electrolyte protocol