Alcohol withdrawal (acute or imminent) should be suspected in any patient who is alcohol-dependent and has stopped or reduced their alcohol intake within hours or days of presentation.
Common symptoms are anxiety, nausea or vomiting, autonomic dysfunction, and insomnia. These may progress to severe withdrawal with seizures, and alcohol withdrawal delirium.
Identify any patient with features of severe alcohol withdrawal early. These patients need urgent treatment. Involve senior support and critical care. Alcohol withdrawal delirium is a life-threatening medical emergency requiring urgent treatment with a benzodiazepine. Patients having seizures also need urgent treatment with a benzodiazepine to reduce the likelihood of further seizures.
Not all patients with symptoms of alcohol withdrawal will need acute drug treatment; those with mild to moderate alcohol withdrawal symptoms can generally be managed with supportive care only. Start a benzodiazepine regimen (fixed-dose or symptom-triggered depending on the clinical setting) for any patient needing acute drug treatment.
Alcohol withdrawal occurs in patients who are alcohol-dependent and who have stopped or reduced their alcohol intake within hours or days of presentation. Symptoms typically begin 6 to 24 hours after the patient's last alcoholic drink, and may progress to life-threatening alcohol withdrawal delirium (also known as delirium tremens), with or without seizures.
History and exam
Key diagnostic factors
- risk factors
- alcohol dependence
- cessation or reduction in alcohol intake
- at least one feature of alcohol withdrawal
- alcohol withdrawal delirium
- coarse tremor
- hypertension or hypotension
- fever or hypothermia
- hyperglycaemia or hypoglycaemia
Other diagnostic factors
- nausea and vomiting
- autonomic dysfunction
- craving for alcohol
- history of alcohol withdrawal syndrome (AWS) and alcohol withdrawal delirium
- abrupt withdrawal of alcohol
1st investigations to order
- venous blood gas
- blood glucose
- full blood count
- urea and electrolytes
- liver function tests
- bone profile
- coagulation studies
Investigations to consider
- blood cultures
- CT head
- chest x-ray
- lumbar puncture
- electroencephalography (EEG)
- blood-borne virus screen
suspected alcohol withdrawal and CIWA-Ar score ≥10 or GMAWS score ≥2
suspected alcohol withdrawal and CIWA-Ar score <10 or GMAWS score <2
Alexander Alexiou, MBBS, BSc, DCH, FRCEM, Dip IMC, RCSEd
Emergency Medicine Consultant
Barts Health NHS Trust
Physician Response Unit Consultant
London’s Air Ambulance
Royal London Hospital
AA declares that he has no competing interests.
TK declares that he has no competing interests.
BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:
Hong K. Kim, MD, MPH
Department of Emergency Medicine
University of Maryland School of Medicine
Nicholas J. Connors, MD
Department of Emergency Medicine
Medical University of South Carolina
Consultant Acute/General Medicine
University Hospitals of Leicester NHS Trust
Honorary Senior Lecturer
Department of Medical Education
University of Leicester
NL has worked as an clinical pharmacologist expert witness at criminal, civil, family, and coroner's courts; given lectures on alcohol withdrawal at undergraduate and postgraduate events; published various articles and written book chapters.
Section Editor, BMJ Best Practice
AS declares that she has no competing interests.
Lead Section Editor, BMJ Best Practice
TAO declares that she has no competing interests.
Comorbidities Editor, BMJ Best Practice
JC declares that she has no competing interests.
Drug Editor, BMJ Best Practice
AM declares that he has no competing interests.
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