Emergent Care / Stabilization:
Patients presenting to the emergency department (ED) with alcohol withdrawal may display varying symptoms and severity. Many of these may be challenging to differentiate from other emergent conditions (eg, epilepsy, alcohol intoxication, altered mental status from unknown etiology, and trauma), so it is imperative for emergency providers to perform comprehensive history and physical examinations for patients presenting with alcohol withdrawal syndrome.

Action items that are warranted in the first 30 minutes are a focused history and physical examination to rule out other emergent etiologies. If patients arrive in status epilepticus or in delirium tremens (DT), they must be prioritized in acuity and assigned to the highest level of care available in the ED. Emergent and expedited intravenous (IV) lines must be placed, and if actively seizing, patients should have their seizures aborted, preferably with IV benzodiazepines. If the seizures do not abort, patients may require endotracheal intubation for airway protection. Patients who require endotracheal intubation due to recalcitrant seizures should be placed on an infusion with phenobarbital or another gamma-aminobutyric acid (GABA) agonist such as propofol or midazolam. Patients will need advanced head imaging, such as CT scan, MRI, and/or neuro telemetry. This should be under the guidance and assistance of an intensivist and neurologist and will require intensive care unit (ICU) admission. Further, patients should be fully examined to ensure no additional signs of trauma or infection are present.

Of the 5 million ED visits annually in the United States due to alcohol consumption, most are not due to alcohol withdrawal seizures. Instead, many patients present to the ED with mild symptoms of alcohol withdrawal syndrome. This can include but is not limited to insomnia, restlessness, palpitations, nausea, and headache. Patients with alcohol withdrawal syndrome may be treated with oral or IV GABA agonists (such as chlordiazepoxide or midazolam); however, patients should receive an IV and be assessed for other emergent conditions. This can be completed by calculating a Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA-Ar) score to determine the patient's baseline score and also obtaining an ECG, basic bloodwork (complete metabolic panel, CBC), and placing the patient on telemetry. The patient should be assessed for other medical etiologies that could be presenting as alcohol withdrawal syndrome (eg, arrhythmias, infection, trauma, thyroid disease). About 50% of patients with alcohol use disorder will have alcohol withdrawal symptoms, and up to 5% will present with DT. The same general types of support needed for any patient with alcohol withdrawal syndrome are true for patients with DT, mainly benzodiazepines. A functioning IV line should be established, and care should be taken when administering glucose to avoid precipitating Wernicke encephalopathy or thiamine-related cardiomyopathies (see alcoholic cardiomyopathy). Thus, thiamine (500 mg infused IV over 30 minutes) should be given in the ED. Additionally, other causes of delirium should be sought to identify and treat any alternative diagnosis that may have contributed to the acute withdrawal syndrome. Given the likelihood of decompensation of patients with DT, these patients should typically be admitted to the ICU.

Diagnosis Overview:
Alcohol is a nervous system depressant, depressing alpha- and beta-adrenergic receptors and enhancing GABA concentration and receptor activity in the brain. Therefore, alcohol withdrawal in a dependent person may cause depression of the GABA inhibitory pathway in the brain. This leads to excitation of the nervous system that manifests as tremors, tachycardia, diaphoresis, and restlessness. Symptoms of withdrawal can begin within 6 hours of drinking cessation. Alcohol withdrawal seizures are generalized convulsions that most often occur within 12-48 hours after alcohol cessation.

Severe withdrawal may cause seizures and electrolyte disturbances. DT is another severe manifestation of alcohol withdrawal and may occur 3-10 days after cessation. DT manifests as confusion, hallucination, and autonomic dysfunction with vital sign instability.

Severe alcohol withdrawal is a life-threatening condition. Alcohol withdrawal is treated with benzodiazepines, which enhance GABA concentration and receptor activity. Thiamine supplementation is also provided to prevent the development of Wernicke-Korsakoff syndrome. CIWA-Ar is an often-used tool to assess the extent of withdrawal and direct therapy.