Advanced•9 min read•High Yield
Alcohol Withdrawal Syndrome - CCS Case Guide
Key Takeaway: Alcohol withdrawal syndrome occurs in patients with chronic heavy alcohol use who abruptly reduce or stop intake. The clinical spectrum ranges from mild tremulousness (6-24 hours) to withdrawal seizures (12-48 hours) and delirium tremens (48-96 hours).
Alcohol withdrawal syndrome occurs in patients with chronic heavy alcohol use who abruptly reduce or stop intake. The clinical spectrum ranges from mild tremulousness (6-24 hours) to withdrawal seizures (12-48 hours) and delirium tremens (48-96 hours). Mortality from untreated delirium tremens can exceed 35%. Early recognition, CIWA-based symptom-triggered benzodiazepine therapy, and aggressive nutritional support are the cornerstones of management on the CCS exam.
Recognizing the Alcohol Withdrawal Presentation
- History: Chronic heavy alcohol use with abrupt cessation or significant reduction in intake within past 24-96 hours; history of prior withdrawal seizures or DTs increases risk
- Autonomic: Tremor (especially hands), diaphoresis, tachycardia, hypertension, and low-grade fever
- Neuropsychiatric: Anxiety, agitation, insomnia, nausea/vomiting, and irritability in early withdrawal
- Seizures: Generalized tonic-clonic seizures typically occurring 12-48 hours after last drink, often in brief clusters
- Delirium Tremens: Severe agitation, global confusion, vivid hallucinations (visual > tactile > auditory), autonomic hyperactivity, and profound diaphoresis occurring 48-96 hours after last drink
- Physical Exam: Coarse tremor, hyperreflexia, diaphoresis, conjunctival injection, and signs of chronic liver disease (spider angiomata, palmar erythema, hepatomegaly)
- Vital Signs: Tachycardia, hypertension, tachypnea, and fever (especially with DTs)
Immediate Actions (First 5 Minutes)
These orders should be placed immediately — timing is scored:
Critical First Orders
- ✓ IV access and continuous telemetry monitoring
- ✓ Initiate CIWA-Ar protocol with assessments every 1-2 hours
- ✓ Administer thiamine 500 mg IV before any glucose-containing fluids
- ✓ Administer IV benzodiazepine (chlordiazepoxide or lorazepam) for CIWA score >= 10
- ✓ IV normal saline bolus for volume depletion
- ✓ Fingerstick glucose to rule out hypoglycemia
- ✓ Place seizure precautions
- ✓ Obtain stat BMP, CBC, magnesium, phosphate, LFTs
Complete Workup
After initial stabilization, complete the diagnostic workup:
- BMP (glucose, electrolytes, BUN/creatinine)
- CBC with differential
- Hepatic function panel (AST, ALT, GGT, alkaline phosphatase, albumin, bilirubin)
- Magnesium and phosphate levels
- Coagulation studies (PT/INR)
- Blood alcohol level
- Urine drug screen
- Lipase (pancreatitis is common comorbidity)
- Serum ammonia if altered mental status
- CT head if first seizure, focal neurological deficits, or head trauma
- Chest X-ray if fever or respiratory symptoms (aspiration risk)
- ECG for QTc prolongation and electrolyte-related arrhythmias
Treatment
Benzodiazepines (CIWA-guided)
- Chlordiazepoxide 25-100 mg PO every 4-6 hours for CIWA 10-18 (mild-moderate)
- Lorazepam 2-4 mg IV every 15-30 minutes for CIWA >= 20 or severe symptoms
- Lorazepam preferred in hepatic dysfunction (no hepatic metabolism)
- Diazepam 10-20 mg IV for rapid control in severe withdrawal or DTs
- Phenobarbital 130-260 mg IV as adjunct for benzodiazepine-refractory cases
Nutritional Repletion
- Thiamine 500 mg IV three times daily for 3 days (high-dose Wernicke prophylaxis)
- Folic acid 1 mg PO daily
- Multivitamin daily
- Magnesium sulfate 2 g IV if hypomagnesemia
- ALWAYS give thiamine BEFORE glucose to prevent Wernicke encephalopathy
Supportive Care
- IV normal saline for volume repletion
- NPO if actively seizing or severely altered
- Correct electrolyte abnormalities (potassium, magnesium, phosphate)
- DVT prophylaxis once stable
Seizure and DT Management
- Lorazepam 2-4 mg IV for active seizures
- Do NOT use phenytoin for isolated alcohol withdrawal seizures (ineffective)
- ICU admission for delirium tremens with aggressive IV benzodiazepine dosing
- Consider propofol or dexmedetomidine for ICU-level refractory DTs
- Mechanical ventilation if airway compromise from sedation or DTs
Common Pitfalls
Scoring Tip: These are the most commonly missed actions for Alcohol Withdrawal cases.
- Giving glucose before thiamine, precipitating acute Wernicke encephalopathy
- Using phenytoin for alcohol withdrawal seizures (it is ineffective; benzodiazepines are the treatment)
- Using a fixed-dose benzodiazepine schedule instead of symptom-triggered CIWA protocol
- Failing to recognize delirium tremens as distinct from simple withdrawal (DTs have global confusion and hallucinations)
- Discharging too early without adequate observation (DTs can present 48-96 hours after last drink)
- Not checking magnesium, which can lower seizure threshold if depleted
- Missing concurrent pathology (subdural hematoma, pancreatitis, GI bleeding) in an altered patient
Disposition
- Admit to ICU for delirium tremens, refractory seizures, or hemodynamic instability
- Admit to medical floor for moderate withdrawal requiring frequent CIWA monitoring
- Observe in ED for 6-8 hours for mild withdrawal (CIWA < 10) before safe discharge
- Arrange addiction medicine or substance abuse counseling referral at discharge
- Schedule outpatient follow-up within 1 week with primary care
Key Orders Checklist
- ☐ CIWA-Ar protocol every 1-2 hours
- ☐ Chlordiazepoxide or lorazepam per CIWA protocol
- ☐ Thiamine 500 mg IV TID x 3 days
- ☐ Folic acid 1 mg PO daily
- ☐ Multivitamin PO daily
- ☐ BMP and magnesium every 12 hours
- ☐ Seizure precautions
- ☐ Continuous telemetry
- ☐ Blood alcohol level on admission
- ☐ Strict I/O monitoring
- ☐ Fall precautions
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