🚨 Alcohol Withdrawal

Alcohol withdrawal syndrome occurs when heavy, prolonged alcohol use is suddenly reduced or stopped. It is a potentially life-threatening condition ranging from mild anxiety to severe delirium tremens and seizures, requiring prompt recognition and management.

Recognise alcohol withdrawal by a history of heavy alcohol use followed by cessation or reduction, presenting with symptoms like tremor, anxiety, nausea, sweating, palpitations, and insomnia. More severe forms include hallucinations, seizures, and delirium tremens (confusion, disorientation, agitation, autonomic hyperactivity).

Perform an ABCDE assessment, paying close attention to vital signs (tachycardia, hypertension, hyperthermia) and neurological status (tremor, agitation, GCS). Assess for signs of dehydration or malnutrition. Obtain a collateral history if possible regarding alcohol intake and last drink. Use a validated scoring tool like CIWA-Ar if appropriate.

Red flags include seizures, delirium tremens, severe agitation, hyperthermia, significant autonomic instability, or evidence of Wernicke's encephalopathy (ataxia, ophthalmoplegia, confusion). Any rapid deterioration in GCS or vital signs warrants urgent attention.

Bedside: Capillary blood glucose, vital signs, ECG (for arrhythmias, electrolyte abnormalities). Bloods: FBC, U&Es (hypokalaemia, hypomagnesaemia), LFTs, CRP, ABG (for metabolic acidosis), alcohol level (if recent ingestion). Imaging: CT head if head injury or other neurological pathology is suspected (e.g., seizure, focal deficit).

Provide a safe, quiet environment. Administer benzodiazepines (e.g., lorazepam or diazepam) to control agitation, prevent seizures, and reduce withdrawal symptoms, titrating to effect. Give parenteral thiamine (e.g., Pabrinex) to prevent Wernicke's encephalopathy. Correct electrolyte abnormalities, especially hypomagnesaemia and hypokalaemia. Ensure adequate hydration and nutrition.

Escalate to a senior registrar or consultant for severe withdrawal symptoms (delirium tremens, recurrent seizures), inadequate response to initial benzodiazepine doses, or development of Wernicke's encephalopathy. Consider critical care referral for patients with severe autonomic instability, refractory seizures, or multi-organ dysfunction.

Delirium tremens is a medical emergency with high mortality if untreated. Always give thiamine before or with glucose to prevent Wernicke's encephalopathy. Benzodiazepines are the mainstay of treatment. CIWA-Ar score guides management and dose titration. Be aware of co-existing conditions like liver disease or infection.