Alcohol withdrawal

Withdrawal sx by time after last drink

Day 1 Day 2 Day 3 Day 4 Day 5-10 
"Shakes"            
Seizures            
  Hallucinosis          
            Delirium tremens

CIWA (Clinical Institute Withdrawal Assessment) protocol - score > 8-10 may require benzo treatment

Symptoms Window Treatment
Minor withdrawal
(Tremulousness, irritability, anorexia, nausea, hallucinosis)		 12-48 hrs Thiamine 100 mg IV then 100 mg/d PO
Multivitamin w/ folate
PRN *Librium (chlordiazepoxide) 25-100 mg PO q6h (adjust till calm but not sedated)
Seizures Exclude other causes (epilepsy, head trauma, hypoglycemia (give thiamine 100 mg IV before glucose))
AEDs not indicated if typical EtOH withdrawal seizure
Severe withdrawal/delirium tremens
(Withdrawal + autonomic hyperactivity (fever, tachycardia, diaphoresis))
(DTs in 5-10% of cases; mortality up to 15%!)		 3-5 days

*Librium 100 mg IV or PO q2-6 hrs PRN, with taper:

  • First 24 hrs: max 500 mg
  • Next 24 hrs: 1/2 initial 24-hr dose
  • Each day after: reduce by 25-50 mg/d

Correct electrolytes (prone to ↓ Mg, K, glucose; dehydration)
Consider other causes of delirium as well
  • *Librium is hepatically cleared
    • If poor drug clearance (e.g. elderly), use short-acting Ativan/lorazepam - 1-2 mg PO/IV q6-8hrs PRN
    • In severe hepatic failure use oxazepam (Serax) (renally excreted) - 15-30 mg PO q6-8hrs PRN
  • Librium takes 2-4 hrs for onset of action
author: admin | last edited: Feb. 23, 2018, 5:06 p.m. | pk: 105