⚠️ Alcohol Withdrawal (Delirium Tremens, DTs) typically develops 48–72 hours after cessation of heavy drinking. 👉 Always ask when the last drink was consumed. 💊 Prevent DTs with long-acting benzodiazepines.

🚑 Acute Alcohol Withdrawal Management
Provide ABC support and monitor vital signs. Consider ITU if seizures are uncontrolled. Administer IV Pabrinex (2 pairs) immediately, then TDS for 2 days. Chlordiazepoxide 25 mg TDS PO or Diazepam 10 mg PO 8-hourly, taper based on CIWA-Ar score. For seizures: Lorazepam 2–4 mg IV/IM. CT head if concern about head trauma or confusion. Add PPI and antiemetics if required.

📊 Alcohol Withdrawal Scale (AWS)

Somatic (0–3): pulse, diastolic BP, temperature, respiratory rate, sweating, tremor.
Mental (0–4): agitation, contact, orientation, hallucinations, anxiety.
Scoring:
- <5 = Mild withdrawal
- 6–9 = Moderate withdrawal
- >9 = Severe withdrawal

🧮 CIWA-Ar Scale

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised) guides benzodiazepine therapy. Max score = 67. Each item is rated 0–7 (except orientation 0–4).

0–8: Minimal withdrawal – usually no meds
9–14: Mild – consider benzodiazepines
15–20: Moderate – treatment required
>20: Severe – frequent dosing ± ICU monitoring

📝 CIWA-Ar Items

Anxiety
Agitation
Auditory disturbances
Orientation/sensorium
Paroxysmal sweats
Tactile disturbances
Tremor
Visual disturbances
Headache
Nausea & vomiting

💡 PRN benzodiazepines if CIWA-Ar ≥8 (symptom-triggered) or ≥15 (if on reducing regime).

🧪 Neurochemistry

Alcohol is a CNS depressant acting on GABA and NMDA receptors.
Chronic use → thiamine depletion, essential for carbohydrate metabolism.
Withdrawal = excess glutamate activity, excitotoxicity & oxidative stress.

💊 Management

Supportive care: calm, well-lit environment, fluids, nutrition, thiamine.
IV Pabrinex: 2 pairs stat, then TDS × 5 days (always before glucose) → prevents Wernicke-Korsakoff syndrome.
Benzodiazepines:
- Chlordiazepoxide 20–40 mg PO q6–8h → taper 3–5 days.
- Diazepam 10 mg PO q8h × 24h → then reduce.
- Lorazepam 2–4 mg IM if unable to take orally.
CIWA-Ar monitoring: reassess q1–4h and titrate dose.
❌ Avoid haloperidol – lowers seizure threshold.

⚡ Risk Factors for Severe Withdrawal

High alcohol intake (>15 units/day)
History of seizures/DTs
Comorbid psychiatric or medical illness

🔍 Investigations

FBC, U&E, LFTs, CRP, Ca, Mg, glucose, coagulation profile
CT head if altered mental status persists or head trauma suspected

📚 References

Delirium Tremens: Assessment and Management (2018)

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Alcohol Withdrawal (Delirium Tremens)