Alcohol Withdrawal and Delirium Tremens

Alcohol withdrawal is what happens when heavy, regular drinking stops or drops off. The ASAM 2020 guideline uses DSM-5 criteria for alcohol withdrawal and alcohol withdrawal delirium. The spread is wide: tremor and autonomic overactivity at one end, withdrawal seizures and delirium tremens (DTs) at the other.

Chronic alcohol boosts GABA-A inhibition and dulls glutamate signaling. When intake stops, the balance tips toward excitation. Repeated withdrawal episodes sensitize the brain (kindling). The next episode can be more severe.

• Triggers: stopping abruptly after heavy, regular drinking. Cutting back can trigger it too, not only full cessation (ASAM).
• Risk for severe or complicated withdrawal: prior withdrawal seizures or delirium, many earlier withdrawal episodes, comorbid illness (especially traumatic brain injury), age over 65, long duration of heavy use, a seizure during the current episode, marked autonomic hyperactivity, and physiological dependence on benzodiazepines or barbiturates.
• Timeline: early signs begin 6–24 hr after the last drink; seizures begin as early as 8 hr, last up to 48 hr and peak around 24 hr; delirium appears 72–96 hr after the last drink and usually lasts 2–3 days. Older patients may follow a different timeline.
• Other substances: sedatives, opioids and stimulants change the picture. Each can produce its own withdrawal. Ask about polysubstance use, and treat each withdrawal syndrome present.

Presentation

Early withdrawal looks like anxiety, insomnia, nausea, tremor, sweating and a fast heart rate. Blood pressure runs high, the reflexes are brisk and sometimes there is hyperthermia. Hallucinations typically start 12–24 hr after the last drink. If delirium does not develop, they usually clear within 24–48 hr.

Severity by CIWA-Ar

Red Flags

• Seizure: any withdrawal seizure gets a benzodiazepine, a glucose check and emergency evaluation.
• Delirium: disorientation, fluctuating attention, agitation or hallucinations, usually from 72–96 hr after the last drink.
• Autonomic instability: heart rate or blood pressure that keeps rising despite treatment, or hyperthermia.
• Respiratory depression: SpO₂ <90%, falling RR or rising EtCO₂ after a sedating dose.
• Hypoglycemia: glucose <70 mg/dL, or confusion or coma without a clear cause.

PAWSS and LARS are the risk scores, and they flag who is headed for severe withdrawal (ASAM). Use them to pick the level of care. They do not stand in for the CIWA-Ar or your judgment. Pregnancy testing is required for women of childbearing potential (ASAM).

• Hypoglycemia: it copies withdrawal. Sweating, tremor, tachycardia and confusion look the same. Check glucose first.
• Wernicke encephalopathy: confusion, ataxia, nystagmus or ophthalmoplegia in a heavy drinker or a malnourished patient? Give thiamine.
• Head injury or subdural hematoma: falls, unclear timing and focal signs or headache. Withdrawal does not explain a focal deficit.
• Other withdrawal or intoxication: benzodiazepine, barbiturate, gabapentinoid or stimulant use, and each can bring its own withdrawal. Treat each syndrome present.
• Sepsis, pneumonia, meningitis or hypoxia: look for fever, a source, meningismus or low SpO₂. ASAM directs clinicians to rule out other serious illness that can mimic withdrawal.
• Hepatic encephalopathy: asterixis and liver failure, with a raised ammonia. It can sit alongside withdrawal.

1. Scene and history: ensure safety, then ask the time of the last drink, the amount, other drugs (opioids, benzodiazepines, sedatives) and prior seizures or DTs.
2. Glucose: check it when the patient is confused, sweating, shaking or seizing, if your protocol allows.
3. Airway and breathing: position on the side if vomiting or seizing, suction, give oxygen per protocol and assist ventilation if breathing is poor.
4. Seizure: protect from injury, time the event, and do not put anything in the mouth. Restrain only to prevent injury, and follow state law.
5. Agitation: speak calmly, reduce stimulation and reorient. Do not give sedating medication unless your scope allows it.
6. Monitoring: vital signs, SpO₂, mental status and CIWA-Ar if your protocol uses it. Record every change.
7. Priority: any seizure, delirium or severe signs need ALS care and transport to an ED. Do not leave the patient alone at the scene.

Doses vary by protocol; follow local protocols and medical direction. Anything above BLS scope carries a (Paramedic/RN/CCT) tag.

• Access and glucose (Paramedic/RN/CCT): IV or IO access; bedside glucose; treat glucose <70 mg/dL per protocol.
• Thiamine (Paramedic/RN/CCT): thiamine 100 mg IV or IM before or with dextrose, then daily for 3–5 days (ASAM). Either order works, but never delay dextrose. See Thiamine.
• Benzodiazepine (Paramedic/RN/CCT): diazepam 10 mg IV or IM, then 5–10 mg in 3–4 hr if needed (label). Push IV no faster than 5 mg/min (about 1 min per 5 mg). Don't dilute it, and skip the small veins of the hand or wrist. Prefer IV or IO when you have access. IM absorption is slower and less predictable (general pharmacology; the label does not address this). Symptom-triggered protocols may repeat sooner, titrating to CIWA-Ar and sedation, and stop for oversedation. See Diazepam.
• Withdrawal seizure (Paramedic/RN/CCT): a seizure that has stopped: lorazepam 2 mg IV once is the trial dose to prevent a recurrent withdrawal seizure (off-label). For an ongoing seizure, one lasting 5 minutes or more, or repeated seizures without recovery, follow the Status Epilepticus protocol (AES: lorazepam 0.1 mg/kg IV, max 4 mg per dose; midazolam IM; or diazepam IV, per protocol). Whenever IV lorazepam is given, do not exceed 2 mg/min (label). The lorazepam label's seizure indication is IV. IM lorazepam is an alternative only where protocol allows. See Lorazepam.
• Airway (Paramedic/RN/CCT): if sedation deepens or breathing fails, bag-valve-mask ventilation, then rapid sequence intubation per protocol.
• Magnesium: replace only for deficiency or arrhythmia. Magnesium does not treat withdrawal itself (ASAM).
• Do not give: phenytoin for withdrawal seizures unless a separate seizure disorder exists; alpha-2 agonists or beta-blockers to prevent seizures; oral or IV alcohol.

• Supportive care: correct volume deficit with IV fluid per protocol; replace potassium, magnesium and phosphorus; give a multivitamin and folate per protocol.
• Labs: CBC, metabolic panel with liver enzymes, and magnesium. Treatment does not wait for results (ASAM). Replace phosphorus once it drops below 1 mg/dL.
• Dosing method: symptom-triggered benzodiazepine dosing is preferred. Front-load with diazepam or chlordiazepoxide when CIWA-Ar is 19 or higher. Chlordiazepoxide is ASAM's preferred front-loading agent. Its sample regimens sit in the guideline (dosing per local protocol, not reproduced here). Oral diazepam example: 10 mg every hour while CIWA-Ar is 10 or higher, or 20 mg every 2 hr for 3 doses (ASAM). Oral label dose: 10 mg 3–4 times in the first 24 hr, then 5 mg 3–4 times daily as needed.
• Resistant withdrawal: uncontrolled symptoms after more than 150–200 mg diazepam or 30–40 mg lorazepam in the first 3–4 hr. Then add an adjunct and reassess the level of care (ASAM).
• Phenobarbital adjunct (ED or ICU, per protocol): a single 10 mg/kg IV dose in 100 mL normal saline over at least 30 min (ASAM), given on top of the benzodiazepines already given, so cumulative sedation needs watching. The weight basis (ideal or actual) depends on protocol. Confirm the maximum total dose with local protocol or pharmacy. Used for moderate to severe withdrawal in admitted adults (GRACE-4 suggestion, low to very low certainty). Adult rate ≤60 mg/min. See Phenobarbital.
• Delirium: benzodiazepines are first-line. Give them IV when possible, to light somnolence. Very large doses may be needed. With repeated high IV doses, monitor sodium and acid-base status (ASAM). If delirium runs past 72 hr, check for another GABAergic withdrawal, such as gabapentin or carisoprodol.
• Adjuncts, never monotherapy: antipsychotics (see Haloperidol) for hallucinations or agitation that persist on benzodiazepines. Dexmedetomidine for autonomic signs (see Dexmedetomidine). Beta-blockers only for persistent hypertension or tachycardia after benzodiazepines.
• ICU adjuncts: propofol is an appropriate adjunct for resistant withdrawal in the ICU (ASAM). Plan analgosedation and the airway per analgosedation protocols.
• If benzodiazepines are contraindicated (mild to moderate withdrawal only): carbamazepine or gabapentin are appropriate ASAM-listed alternatives. Phenobarbital is another option for experienced clinicians, mainly in inpatient settings. Benzodiazepines remain first-line. These alternatives are not for severe withdrawal, seizure or delirium. Avoid valproate in liver disease or in people who could become pregnant (ASAM).
• Thiamine in the ICU: when signs mimic or mask Wernicke encephalopathy, IV thiamine 200–500 mg every 8 hr (ASAM ICU range). See Thiamine.
• ICU admission: one protocol calls for ICU care at 200 mg diazepam in 4 hr or a single IV dose over 40 mg (cited by ASAM). Use your local threshold.
• Disposition: after a withdrawal seizure, admit to a setting with close monitoring. Reassess every 12 hr for 6–24 hr, and watch for fluid and electrolyte shifts (ASAM).

• Destination: severe withdrawal (CIWA-Ar 19 or higher), any seizure or delirium, or no settling after an adequate benzodiazepine dose goes to the nearest ED (ASAM). For resistant or complicated withdrawal, pick an ED with ICU capability.
• Monitoring in transit: continuous SpO₂ and EtCO₂ after any benzodiazepine; RR, BP, HR, mental status and glucose at the protocol interval; seizure precautions.
• Repeat dosing in transit: transport time and sedation limit symptom-triggered repeat benzodiazepine doses. Reassess before each dose. Give further doses only per protocol and medical direction.
• Airway: vomiting or sedation raises aspiration risk. Keep suction ready and have a plan for airway support.
• Drugs to carry: benzodiazepine (diazepam or lorazepam), thiamine, dextrose and airway equipment. IV phenobarbital belongs in highly supervised settings (ICU, CCU) per ASAM. Do not start a phenobarbital load in transit unless the receiving team is ready.
• Handoff essentials: time of last drink, each benzodiazepine dose with its time and cumulative mg, seizure times, glucose results, CIWA-Ar trend and thiamine time.
• Restraint: restrain only to prevent injury, under state law and local protocol. Document why and reassess.

• Pediatrics: alcohol withdrawal in children and adolescents is uncommon. The ASAM 2020 adult guideline gives no pediatric doses. For a seizure, use pediatric status epilepticus dosing: lorazepam 0.1 mg/kg IV (max 4 mg) per the Lorazepam page, with weight-based dosing. Bring in pediatric critical care or a toxicology service.
• Pregnancy: ASAM recommends inpatient withdrawal care for pregnant patients with at least moderate withdrawal. Use the CIWA-Ar as the scale, and get an obstetric consult. Fetal monitoring depends on gestation. Benzodiazepines given in late pregnancy can cause neonatal sedation and withdrawal (diazepam label). Tell the receiving team.
• Older Adults: age over 65 raises the risk of complicated withdrawal. Long-acting benzodiazepine metabolites build up in older adults. Use lower doses and monitor closely (ASAM).
• Hepatic Impairment: when significant liver disease is present or results are pending, ASAM favors a benzodiazepine with less hepatic metabolism, such as lorazepam.
• Patients on Beta-Blockers: beta-blockers do not prevent or treat withdrawal seizures or delirium. They can mask autonomic signs, so reassess by mental status, not heart rate alone. Use them only for persistent hypertension or tachycardia after benzodiazepines (ASAM).
• Opioid or Sedative Co-Use: respiratory depression adds up. The diazepam label carries a boxed warning for opioid co-use. Monitor SpO₂ and EtCO₂ continuously.

• Error: flumazenil for a dependent patient. Flumazenil reverses benzodiazepine effect. In a patient physically dependent on benzodiazepines, it can precipitate withdrawal seizures. Support the airway and treat with a benzodiazepine. Use flumazenil only with medical direction.
• Error: phenytoin for withdrawal seizures. ASAM advises against phenytoin unless a separate seizure disorder is present. Benzodiazepines come first.
• Error: holding dextrose for thiamine. Thiamine and glucose can go in any order, or together. Glucose is never delayed for thiamine.
• Error: scoring delirium with the CIWA-Ar. Self-report scores are unreliable in delirium. Switch to CAM-ICU, RASS or MINDS.
• Error: stopping at a number when symptoms persist. Symptoms persist without oversedation? Keep dosing to symptoms and CIWA-Ar. Once the resistant-withdrawal threshold (more than 150–200 mg diazepam or 30–40 mg lorazepam in the first 3–4 hr) is passed, or oversedation limits dosing, add an adjunct and reassess the level of care (ASAM).
• Error: alpha-2 agonist or beta-blocker alone for a seizure. They do not prevent or treat withdrawal seizures or delirium. They can mask autonomic signs of withdrawal, so reassess mental status and seizure risk, not heart rate alone.
• Error: dismissing withdrawal because of a positive alcohol level. A positive level does not rule withdrawal in or out (ASAM).