2. Objectives
Discuss the symptoms and signs of alcohol withdrawal.
Discuss the management of alcohol withdrawal.
3. Case 1
70-yo M with unknown PMHx was brought into ED after
being found down. Pt was found to have displaced hip
fracture and was taken to OR for ORIF. Pt initially did
well post-op, but 48 hrs after admission pt started
having tachycardia, hypertension, fever, and agitation.
What are some differential diagnosis?
5. What’s in Quest CIWA order set?
Vital signs q4h, cardiac monitoring, pulse oximetry,
fall/seizure/ aspiration precautions.
CIWA scores (components of CIWA: N/V, sweats,
anxiety, agitation, tremor, HA, auditory/ visual/ tactile
disturbances, orientation and clouding of sensorium).
“banana bag”: NS with 100mg thiamine, 1g folate, and
multivitamin.
PRN IV Ativan 2mg for CIWA 10-15, 4mg for CIWA> 15.
6. What is not in the order set?
Electrolyte replacement: especially watch out for low K,
low Mg, and low phos!
7. When do you call the ICU?
Status epilepticus
Possible DTs, esp. persistent hyperthermia,
hemodynamic instability
Severe electrolyte or acid/base disturbances
Severe withdrawal symptoms, requiring large amount of
benzodiapezines.
8. Case 2
40-yo M with h/o alcohol abuse presented with
palpitations, nausea/ vomiting, and tremors.
Pt drinks half a gallon of vodka daily and reports that his
last drink was approximately 12 hours prior to
admission. On further questioning, pt reports history of
alcohol withdrawal seizures and has been admitted to
OSH ICUs in the past for alcohol withdrawal.
In the ED, pt is tremulous, afebrile, has regular
tachycardia, slightly hypertensive.
9. Which protocol do you initiate to monitor and manage
withdrawal symptoms?
Which electrolytes do you check?
What IVF and medications do you order?
When is the pt at greatest risk for alcohol withdrawal
seizures? For DTs?
Under what circumstances would you call the ICU?
10. Summary
Depending on the time of last drink, there are
symptoms/ signs and possible complications to watch
out for and manage.
Initiate CIWA protocol when patient was admitted with
possibility of alcohol withdrawal, include IV fluid,
vitamins, and prn lorazepam.
Don’t forget to check and replace electrolytes.
Sepsis, drug intoxication/ withdrawal, alcohol withdrawal (esp. DT)
Minor withdrawal (“the shakes”): tremulousness, anxiety, GI upset, headache, diaphoresis. 6-36 hours after last drink.
Seizures: 6-48 hours after last drink
Alcoholic hallucinosis: visual/ auditory/ tactile hallucinations, with intact orientations and stable vital signs. 12-48 hours after last drink.
Delirium tremens: delirium, agitation, tachycardia, hypertension, fever, diaphoresis. 48-96 hours after last drink.
H/o ICU admissions for alcohol suggests pt may have had DTs in the past. Pt also at increased risk if + h/o seizures and prolonged heavy alcohol use.
Labs: electrolytes, Mg, Phos. CIWA order set. “banana bag”, prn Ativan. Seizures can occur 6-48 hrs after last drink, DTs 48-96 hrs after last drink.
