Criteria

Excitatory - Occur after 6-12 hrs of cessation.

Tremor (6-8hr) → Hallucination (12-24 hr) → !Seizure (12-48h) → !Delirium tremens (2-5 dys) (2-5 days)

Stage 1	Stage 2	Stage 3	Stage 4	Stage 5
Time of last drink	6-8 hours	12-24 hours	12-48 hours	2-5 days
Definition	Mild withdrawal
(in some cases can progress to DTs)	Alcoholic Hallucinosis
(in some cases can progress to DTs)	Withdrawal Seizures	Delirium Tremens (DTs)[8], 5% mortality
Symptoms	• Mild tremors• Anxiety• Nausea	• Stable Vitals• Tremors• Agitation• Insomnia• Hallucination (auditory, visual, tactile), but insight is maintained	• Same as Stage 2, but more severe• Seizures	• Unstable Vitals• Confusion• Agitation• Fever• Tachycardia• Hypertension• Diaphoresis

Treatment

Inpatient Management

Indication for inpatient

Benzodiazepine (’-azepam’)

	Uncomplicated withdrawal	Complicated withdrawal
Definition	No history of siezures or delirium tremens	A history of withdrawal seizures, delirium tremens
pregnancy or geriatric
CIWA -A/B(< 10)
Q6h	Start right away.	Start after loading dose (x3)
Diazepam	20mg PO q1-2h	20mg q1h x 3 = 60mg
‣	2mg q1-2h	2mg q1h x 3 = 6mg

B1 - Thiamine
- 200mg IV thiamine x 3 days
- 500 mg if suspect Wernicke-korsakoff Syndrome
CIWA -A/B(< 10)
- Q6h until symptom resolves
Supportive Care
1. IV Fluid Resuscitation for Dehydration
2. IV hypotonic (Dextrose/D5W) if suspect Hypoglycemia ↓( ≤ 4)

NOTE:

At 24-48 hr, you can !Seizure with Benzodiazepine (’-azepam’), Propofol, Phenobarbital (NOT Phenytoin)

*anti-epileptics do not work to prevent alcohol-related seizures.
!Delirium tremens (2-5 dys) must be treated with Benzodiazepine (’-azepam’)

Outpatient

QID x 3 days (total 40mg daily)
BID x 3 days (total 20mg daily)