Managing Alcohol Withdrawal in the ED

History: John has been consuming 8-10 beers daily for the past 15 years. He decided to quit drinking two days ago due to family pressure. He has a history of AWS but no previous severe withdrawal episodes.

Physical Exam: The patient presents with moderate tremors, slight tongue fasciculations, mild psychomotor agitation, and intermittent nausea. He reports anxiety and difficulty sleeping but denies any history of seizures or hallucinations.

His CIWA score comes up at 15.

CIWA Protocol is not appropriate for initial AWS management, only after AWS appropriately treated with benzodiazepines or phenobarbital

• Lack of vital sign assessments
• Non-specific, non-diagnostic
• Subject to confounding variables (anxiety, medical comorbidities subjectivity of patient & provider)
• Scoring every 2-4 hours
• Patients must communicate & follow commands

• History: decrease or cession after chronic alcohol use, history of AWS
• Physical Exam: autonomic excitability, tremors, tongue fasciculations, psychomotor, agitation, nausea, vomiting, anxiety, insomnia, seizures
• Rule out other differential dx: drug intoxication, thyrotoxicosis, sepsis, serotonin syndrome/neuroleptic malignant syndrome, hypertensive crisis, acute pain, delirium
• Severity of AWS is a clinical diagnosis (meaning, don’t use CIWA which is very subjective)

For me, a severe EtOH withdrawal is anyone with autonomic instability, obvious hallucinations and psychosis or profound diaphoresis. However, I’d keep a close eye on those with a true history of severe withdrawal requiring ICU admission.

Diazepam should be used cautiously in patients with liver failure (evidence of synthetic dysfunction such as elevated INR or bilirubin) and older adults due to decreased metabolism. In these patients, ==lorazepam== may be preferable.

Lorazepam takes a while to work so you may inadvertently give more and more, thinking it’s not working. Then the doses start to stack.

1. Front-Load
   • Diazepam 10-20mg IV / PO q1 hour until AWS stabilized (first-line)
   • Lorazepam 2-4mg IV /PO q1 hour until AWS stabilized (second-line)
2. Maintenance: start symptom-triggered CIWA scoring AFTER front-loading. ==Now you can use CIWA.==
   • Diazepam PO (first-line)
   • Lorazepam PO (second-line)
3. Consider early use of gabapentin for alcohol withdrawal / alcohol use disorder
   • Gabapentin 400-600mg TID

For the known severe cases, it may be good start with phenobarbital so you don’t have to mix barbiturates and benzodiazepines.

1. Front-Load (clinical goal: until patient is drowsy but arousable)
   • Phenobarbital IV 5-10mg/kg until AWS stabilized can repeat 5mg/kg x q30min, max 20 mg/kg)
     • Once you reach 20 mg/kg, if it’s still not working it may not work. If you get to 30 mg/kg, intubate or something else is going on. It should have worked by now.
   • Diazepam 20mg IV q10 mins until AWS stabilized (doses of 40mg+ may be appropriate if symptoms not improving, consider phenobarbital for patients with benzodiazepine resistance).
     • At a total dose of 200 mg if you haven’t gotten a result it is probably not going to work.
     • You can switch to phenobarbital, but mixing it with diazepam can be dangerous.
     • Time to start thinking intubation + propofol drip.
   • Lorazepam 4mg IV q10 mins until AWS stabilized (first line in special populations, see above)
2. Maintenance: start symptom-triggered CIWA scoring AFTER front-loading
   • Diazepam PO (generally first line, second-line if patient received phenobarbital)
   • Lorazepam PO (==first-line in special populations or if patient received phenobarbital ==to prevent stacking of long-acting barbiturates / benzodiazepines and risk of oversedation)
3. Consider adjuncts for alcohol withdrawal management if benzodiazepines or phenobarbital used as primary agent and didn’t work. At this point, consider intubation.
   • Gabapentin 600mg TID
   • Ketamine
   • Dexmedetomidine (to switch out the propofol drip so that we can avoid propofol infusion syndrome).

1. Discharge
   • Not in alcohol withdrawal after ED treatment (consider gabapentin 600 – 900 mg TID for treatment of AUD and to minimize rebound AWS)
   • Caregiver who can monitor, provide withdrawal medications, and bring back if worsening
   • Ability to seek alcohol detox-specific facilities or reliable follow-up
2. Admission
   • Ongoing / continued AWS despite initial ED management
   • Medical or psychiatric reasons for hospital admission

History: Emily has been drinking heavily for the past 30 years, mainly hard liquor. She has experienced severe AWS before, including episodes of delirium tremens. She stopped drinking abruptly five days ago.

Physical Exam: The patient is experiencing severe autonomic excitability, with pronounced tremors and psychomotor agitation. She reports severe anxiety, constant nausea, and has had multiple episodes of vomiting. She is disoriented and experiencing visual hallucinations.

Rule Out: Negative for drug intoxication, acute pain, and delirium. No signs of sepsis, thyrotoxicosis, or hypertensive crisis. Serotonin syndrome and neuroleptic malignant syndrome are ruled out.

History: John has been consuming 8-10 beers daily for the past 15 years. He decided to quit drinking two days ago due to family pressure. He has a history of AWS but no previous severe withdrawal episodes.

Physical Exam: The patient presents with moderate tremors, slight tongue fasciculations, mild psychomotor agitation, and intermittent nausea. He reports anxiety and difficulty sleeping but denies any history of seizures or hallucinations.

Rule Out: Negative for drug intoxication, thyrotoxicosis, and sepsis. No signs of hypertensive crisis or acute pain. There is no evidence of serotonin syndrome or neuroleptic malignant syndrome.

History: Robert has been consuming large quantities of alcohol (2 liters of wine daily) for the past 20 years. He stopped drinking suddenly one week ago due to health concerns. He has a history of severe AWS with hallucinations and seizures.

Physical Exam: The patient is experiencing severe tremors, significant tongue fasciculations, and severe psychomotor agitation. He reports severe nausea, anxiety, and has had several episodes of vomiting. He is experiencing auditory hallucinations and had a seizure earlier today.

Rule Out: Negative for drug intoxication and sepsis. Thyrotoxicosis and hypertensive crisis have been ruled out. There is no evidence of serotonin syndrome, neuroleptic malignant syndrome, or acute pain.

History: Mark has been drinking heavily (1 liter of vodka daily) for over 25 years. He has a history of multiple withdrawal episodes with seizures. He was hospitalized one year ago for severe AWS and stopped drinking four days ago.

Physical Exam: The patient presents with severe tremors, marked tongue fasciculations, and significant psychomotor agitation. He has experienced multiple episodes of vomiting, severe anxiety, insomnia, and auditory hallucinations. He also had a seizure the previous night.

Rule Out: Negative for drug intoxication and sepsis. Thyrotoxicosis and hypertensive crisis have been ruled out. There is no evidence of serotonin syndrome, neuroleptic malignant syndrome, or acute pain.