II. Epidemiology

  1. Onset: 6-24 hours after last Alcohol intake
  2. Duration: 5-7 days after abstinence
  3. Peak symptoms: 1-3 days after abstinence

III. Risk Factors: Severe withdrawal (Delirium Tremens)

  1. Age >40 years
  2. Heavy drinking >8 years
  3. Alcohol intake >100 grams, >1 pint liquor, >96 oz beer
  4. Patient experiences withdrawal symptoms when abstinent
  5. Hepatic Cirrhosis
  6. Lab abnormalities
    1. Mean Corpuscular Volume (MCV) increased
    2. Blood Urea Nitrogen (BUN) increased
    3. Blood Alcohol level >0.20 g/dl on random draw
  7. Reference
    1. Ferguson (1996) J Gen Intern Med 11:410-4 [PubMed]

IV. Symptoms

  1. Stage 1 symptoms (6-12 hours post-Alcohol)
    1. Anxiety or Panic Attacks
    2. Paresthesias, Shakes or Jitters
    3. Chills, Sweats, or Fevers
    4. Chest Pain or Palpitations
    5. Insomnia
    6. Headache
    7. Nausea or Vomiting
    8. Abdominal Pain
    9. Still coherent
  2. Stage 2 symptoms (24-72 hours post-Alcohol)
    1. Marked agitation, restlessness and diaphoresis
    2. Tremulous with constant eye movements
    3. Nausea, Vomiting, anorexia, and Diarrhea
    4. Sinus Tachycardia >120 bpm
    5. Systolic Hypertension with SBP >160 mmHg
    6. Confusion may be present
    7. Hallucinations (Alcoholic hallucinosis)
      1. Paranoid Delusions or Illusions
      2. Auditory, visual, and Tactile Hallucinations
    8. Withdrawal Seizures (24-48 hours post-Alcohol)
      1. Generalized tonic-clonic Seizures
      2. Brief Seizures (<5 minutes) and may recur
      3. Status Epilepticus is not due to withdrawal
  3. Stage 3 symptoms (Delirium Tremens): 72-96 hours
    1. Visual Hallucinations
    2. Disorientation and Delirium
    3. Severe Tachycardia and Hypertension
    4. Severe agitation and tremulousness
    5. Hyperthermia (Fever, severe diaphoresis)

V. Signs

  1. Blood Pressure, pulse and Temperature elevated
  2. Hyperarousal, Agitation, or Restlessness
  3. Cutaneous Flushing or Diaphoresis
  4. Dilated pupils
  5. Ataxia
  6. Altered Level of Consciousness or Disorientation
  7. Delirium Tremens

VI. Complications: Delirium Tremens

  1. Head Trauma
  2. Myocardial Infarction
  3. Aspiration Pneumonia and other infections
  4. Electrolyte disturbance (e.g. Hypomagnesemia)
  5. Death

VII. Management: General Measures

  1. Seizure precautions
  2. Supplementation
    1. Vitamin Deficiency is common (Vitamins A, C, B1, B3, B6, B9, B12)
      1. See Alcohol Dependence
    2. Thiamine (Vitamin B1) 100 mg orally daily
    3. Folate (Vitamin B9) 1 mg orally daily
    4. Multivitamin daily
    5. Treat Hypomagnesemia if present
  3. Intravenous Fluids (Normal Saline or banana bag)
    1. Frequently administered to intoxicated patients admitted to the Emergency Department
    2. IV Fluids do not shorten the length of ED stay for intoxicated patients (typical ED stay averages 4.5 hours)
      1. Perez (2013) Emerg Med Australas 25(6): 527-34 [PubMed]
  4. Disposition
    1. See Clinical Sobriety

VIII. Management: Agents used in Alcohol Withdrawal

  1. Also see Alcohol Detoxification in Ambulatory Setting
  2. Benzodiazepine choice
    1. Valium and Librium offer lower risk of rebound
      1. Preferred in most cases for long half-life
      2. Librium has less stimulation of reward system (lower abuse potential)
    2. Seizure history: Valium
    3. Liver disease or elderly patient: Ativan or Serax
  3. Benzodiazepine Alternatives (in patients in whom Benzodiazepines are considered too risky)
    1. Precautions
      1. Neither Carbamazepine nor Valproic Acid have been shown to prevent Alcohol Withdrawal Seizure
      2. Adverse risks include Thrombocytopenia and other Bone Marrow suppression, Pancreatitis
    2. Carbamazepine
      1. Effective in moderate withdrawal
      2. Dosing: 200 mg four times daily tapered over 5 days
        1. Start at Carbamazepine (Tegretol) 800 mg on day 1
        2. Finish at 200 mg once on day 5
      3. References
        1. Malcolm (2002) J Gen Intern Med 17:349-55 [PubMed]
    3. Gabapentin
      1. Potentiates CNS GABA activity and decreases glutamate activity
        1. Decreases Alcohol craving and depression
      2. Dosing (minimum effective daily dose 900 mg/day)
        1. Start 600 mg three times daily for 3 days
        2. Then 300 mg three times daily for 3 days
      3. References
        1. Stock (2013) Ann Pharmacother 47: 961-9 [PubMed]
        2. Myrick (2009) Alcohol Clin Exp Res 33(9): 1582-8 +PMID:19485969 [PubMed]
    4. Valproic Acid
      1. Has also been used in Alcohol Withdrawal
  4. Other symptomatic agents
    1. Beta Blockers (Propranolol or Atenolol)
      1. Symptomatic relief of chills, shakes
      2. Improves Vital Signs
      3. Use selective Beta Blocker in Coronary Artery Disease
    2. Haloperidol
      1. Decreases agitation and Hallucinations
      2. May lower Seizure threshold

IX. Management: Symptom-Triggered Regimen (preferred)

  1. Preferred over protocol below
  2. Clinical Institute Withdrawal Assessment (CIWA-Ar)
    1. http://addiction-medicine.org/files/15doc.html
    2. Assess hourly to determine medication need
  3. Give one of following hourly until CIWA-Ar <8-10 points
    1. Librium 50 to 100 mg
    2. Valium 10 to 20 mg
    3. Ativan 2 to 4 mg

X. Management: Mild Alcohol Withdrawal Protocol

  1. Symptom-triggered protocol above is preferred
  2. General Protocol
    1. Diazepam (Valium) 5-10 mg PO prn or
    2. Lorazepam (Ativan) 1-2 mg PO q4-6h prn for 1-3 days
  3. Defining Criteria and Additional Medication Indications
    1. Systolic Blood Pressure > 150 mmHg
    2. Diastolic Blood Pressure > 90 mmHg
    3. Heart Rate > 100
    4. Temperature > 37.7 C (100 F)
    5. Tremulousness, Insomnia, or Agitation

XI. Management: Moderate Alcohol Withdrawal Protocol

  1. Symptom-triggered protocol above is preferred
  2. General Protocol
    1. Diazepam (Valium)
      1. Day 1: 15 to 20 mg PO qid
      2. Day 2: 10 to 20 mg PO qid
      3. Day 3: 5 to 15 mg PO qid
      4. Day 4: 10 mg PO qid
      5. Day 5: 5 mg PO qid
    2. Lorazepam (Ativan)
      1. Days 1-2: 2-4 mg PO qid
      2. Days 3-4: 1-2 mg PO qid
      3. Day 5: 1 mg PO bid
    3. Librium 25-50 mg PO qid
      1. Decrease by 20% per day
  3. Defining Criteria and Additional Medication Indications
    1. Systolic Blood Pressure: 150-200 mmHg
    2. Diastolic Blood Pressure: 100-140 mmHg
    3. Heart Rate: 110-140
    4. Temperature: 37.7 to 38.3 C (100 to 101 F)
    5. Tremulousness, Insomnia, or Agitation

XII. Management: Severe Alcohol Withdrawal Protocol

  1. Symptom-triggered protocol above is preferred
  2. Indicated in Delirium Tremens
  3. General Protocol (Requires ICU observation)
    1. Diazepam (Valium)
      1. Dose: 10-25 mg PO q1h prn while awake
      2. Endpoint: until adequate Sedation
    2. Lorazepam (Ativan)
      1. Dose: 1-2 mg IV q1h prn while awake for 3-5 days
      2. Endpoint: until adequate Sedation
    3. Librium
      1. Dose: 50 to 100 mg PO/IM/IV q4h (max: 300 mg/day)
      2. Endpoint: until adequate Sedation
  4. Defining Criteria and Additional Medication Indications
    1. Systolic Blood Pressure > 200 mmHg
    2. Diastolic Blood Pressure > 140 mmHg
    3. Heart Rate > 140
    4. Temperature > 38.3 C (101 F)
    5. Tremulousness, Insomnia, or Agitation
  5. Additional measures (require Advanced Airway and Ventilatory support)
    1. Phenobarbital 130-260 mg IV prn
    2. Propofol
    3. Dexmedetomidine 0.2 to 0.4 mcg/kg/hour up to 1.2 mg/kg/hour
      1. Do not reduce Benzodiazepine dose when used with Dexmedetomidine

XIII. Resources: Patient Education

  1. Information from your Family Doctor: Alcohol Withdrawal
    1. http://www.familydoctor.org/handouts/007.html

XIV. References

  1. Ferri (2001) Care of Medical Patient, p. 802-5
  2. McMicken in Marx (2002) Rosen Emergency Med, p. 2513-16
  3. Orman and Hayes (2015) EM:Rap 15(11): 7-8
  4. Orman and Starr (2015) EM:Rap 15(12): 10-11
  5. Bayard (2004) Am Fam Physician 69(6):1443-50 [PubMed]
  6. Chang (2001) Med Clin North Am 85(5):1191-212 [PubMed]
  7. Muncie (2013) Am Fam Physician 88(9): 589-95 [PubMed]

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

Ontology: Alcohol Withdrawal Delirium (C0001957)

Definition (MSH) An acute organic mental disorder induced by cessation or reduction in chronic alcohol consumption. Clinical characteristics include CONFUSION; DELUSIONS; vivid HALLUCINATIONS; TREMOR; agitation; insomnia; and signs of autonomic hyperactivity (e.g., elevated blood pressure and heart rate, dilated pupils, and diaphoresis). This condition may occasionally be fatal. It was formerly called delirium tremens. (From Adams et al., Principles of Neurology, 6th ed, p1175)
Definition (PSY) Acute alcoholic, psychotic condition characterized by intense tremors, anxiety, hallucinations, and delusions.
Concepts Disease or Syndrome (T047)
MSH D000430
ICD9 291.0
ICD10 F10.4
SnomedCT 192211007, 154853008, 8635005
DSM4 291.0
English Delirium Tremens, Delirium, Alcohol Withdrawal, Men & behav dis due alcohl: withdrawl state with delirium, Mental and behavioral disorders due to use of alcohol: withdrawal state with delirium, Mental and behavioural disorders due to use of alcohol: withdrawal state with delirium, [X]Alcohol withdrawal delirium, [X]Men & behav dis due alcohl: withdrawl state with delirium, [X]Mental and behavioral disorders due to use of alcohol: withdrawal state with delirium, [X]Mental and behavioural disorders due to use of alcohol: withdrawal state with delirium, Mental and behavioral disorders due to use of alcohol, withdrawal state with delirium, Mental and behavioural disorders due to use of alcohol, withdrawal state with delirium, ALCOHOL WITHDRAWAL IND DELIRIUM TREMENS, DELIRIUM TREMENS ALCOHOL WITHDRAWAL IND, alcohol withdrawal delirium, alcohol withdrawal with delirium, DTs, alcohol withdrawal delirium (diagnosis), alcohol withdrawal delirium ('D. tremens'), Delirium tremens, alcoh-ind, [X]Delirium tremens, alcoh-ind, Delirium tremens, alcohol-induced, [X]Delirium tremens, alcohol-induced, Alcohol Withdrawal-Induced Delirium Tremens, Delirium Tremens, Alcohol Withdrawal Induced, Alcohol Withdrawal Delirium [Disease/Finding], delerium tremens, delirium tremens, dts, Delirium tremens;alcoholic, deliriums tremens, Alcohol Withdrawal Induced Delirium Tremens, Delirium tremens (disorder), [X]Mental and behavioral disorders due to use of alcohol: withdrawal state with delirium (disorder), Alcohol withdrawal delirium, Delirium tremens, DTs - delirium tremens, Alcohol withdrawal delirium (disorder), delirium; alcohol, due to withdrawal, delirium; alcohol, delirium; tremens, intoxication; alcohol, withdrawal state, with delirium, alcohol; delirium, withdrawal, alcohol; delirium, alcohol; intoxication, withdrawal state, with delirium, alcohol; withdrawal state with delirium, alcohol; withdrawal syndrome, with delirium, alcohol; withdrawal, with delirium, syndrome; alcohol withdrawal, with delirium, tremens; delirium, withdrawal state; alcohol, with delirium, withdrawal; alcohol, with delirium, Alcohol Withdrawal Delirium, Alcoholic delirium
French Délirium trémens, Délire induit par le sevrage à l'alcool, Délirium trémens provoqué par le sevrage alcoolique, Délirium trémens dû au sevrage alcoolique, Délirium trémens dû au sevrage à l'alcool, Delirium tremens, Délire alcoolique
Swedish Delirium tremens
Japanese シンセンセンモウ, アルコール離脱譫妄, 振戦せん妄, せん妄-アルコール離脱性, アルコール離脱せん妄, 振戦譫妄, アルコールリダツセンモウ, アルコール離脱性せん妄, アルコール離脱症候群
Czech delirium tremens, alkoholismus - delirium abstinenční, Delirium tremens, Alkoholový odvykací stav s deliriem
Finnish Juoppohulluus
Russian BELAIA GORIACHKA, TROMOMANIIA, DELIRII ALKOGOL'NYI, ALKOGOL'NYI DELIRII PRI VOZDERZHANII, ALKOGOL'NYI DELIRII ABSTINENTNYI, DELIRIUM TREMENS, АЛКОГОЛЬНЫЙ ДЕЛИРИЙ АБСТИНЕНТНЫЙ, АЛКОГОЛЬНЫЙ ДЕЛИРИЙ ПРИ ВОЗДЕРЖАНИИ, БЕЛАЯ ГОРЯЧКА, ДЕЛИРИЙ АЛКОГОЛЬНЫЙ, ТРОМОМАНИЯ
German Psychische und Verhaltensstoerungen durch Alkohol: Entzugssyndrom mit Delir, Alkoholentzugsdelirium, Alkoholentzugsdelir, Delirium tremens, Entzugsdelir, Alkohol-
Italian Delirium tremens, Delirio indotto da astinenza da alcol, Delirium tremens indotto da astinenza da alcol, Delirio da astinenza da alcool, Delirio da astinenza da alcol
Spanish Delirio por abstinencia de alcohol, [X]trastornos mentales y de conducta debidos al uso de alcohol: estado de abstinencia con delirio, [X]trastornos mentales y de conducta debidos al uso de alcohol: estado de abstinencia con delirio (trastorno), delirio por abstinencia de alcohol, delirium por abstinencia de alcohol (trastorno), delirium por abstinencia de alcohol, delirium tremens, Delirium tremens, Delirium por Abstinencia Alcohólica, Delirium Tremens
Portuguese Delírio por abstinência de álcool, Delirium tremens, Delirium por Abstinência de Álcool, Delirium Tremens
Dutch alcoholonthouding delirium, alcohol; delirium bij onthouding, alcohol; delirium, alcohol; intoxicatie, onthoudingstoestand, met delirium, alcohol; onthouding met delirium, alcohol; onthoudingstoestand met delirium, alcoholonthouding; syndroom, met delirium, delirium; alcohol, bij onthouding, delirium; alcohol, delirium; tremens, intoxicatie; alcohol, onthoudingstoestand, met delirium, onthouding; alcohol, met delirium, onthoudingstoestand; alcohol, met delirium, syndroom; alcoholonthouding, met delirium, tremens; delirium, Psychische stoornissen en gedragsstoornissen door gebruik van alcohol; Onthoudingstoestand met delirium, delirium tremens, Delirium tremens
Polish Majaczenie drżenne, Delirium tremens, Majaczenie alkoholowe
Hungarian Delirium tremens, Alkohol megvonási delirium
Norwegian Delirium tremens

Ontology: Detoxication psychiatric therapy for alcoholism (C0204597)

Concepts Therapeutic or Preventive Procedure (T061)
ICD9 94.62
ICD10 92003-00
SnomedCT 151253000, 64297001
Italian Disintossicazione da alcool
Japanese アルコールの解毒, アルコールノゲドク
Czech Detoxikace při léčbě alkoholové závislosti
English alcohol detoxification, alcohol detoxification (treatment), detoxification alcohol, Alcohol detoxification (procedure), Alcohol detoxification, Detoxication psychiatric therapy for alcoholism (regime/therapy), Detoxication therapy for alcoholism, Detoxication psychiatric therapy for alcoholism, Detoxication psychiatric therapy for alcoholism (regime/therapy)(procedure)
Hungarian Alkohol detoxikáció
Spanish desintoxicación alcohólica, terapia de desintoxicación para el alcoholismo (régimen/tratamiento), terapia de desintoxicación para el alcoholismo, terapia psicológica de desintoxicación para el alcoholismo (procedimiento), Desintoxicación alcohólica
Portuguese Desintoxicação alcoólica
Dutch alcoholdetoxificatie
French Détoxication de l'alcool
German Alkoholentgiftungsmassnahme

Ontology: Alcohol withdrawal syndrome (C0236663)

Definition (PSY) Processes and symptomatic effects resulting from abstinence from alcohol. Used for both human and animal populations.
Concepts Disease or Syndrome (T047)
ICD9 291.81
SnomedCT 268745002, 154854002, 191480000
DSM4 291.8
Italian Sindrome di astinenza dall'alcool
Japanese アルコール離脱症候群, アルコールリダツショウコウグン
English alcohol withdrawal, alcohol withdrawal (diagnosis), withdrawal alcohol, alcohol syndrome withdrawal, alcohol withdrawal syndrome, alcohol syndromes withdrawal, alcohol withdrawals, Withdrawal syndrome - alcohol, Alcohol withdrawal syndrome (disorder), intoxication; alcohol, withdrawal state, alcohol; abstinence symptoms or syndrome, alcohol; intoxication, withdrawal state, alcohol; withdrawal state, alcohol; withdrawal syndrome, alcohol; withdrawal, syndrome; alcohol withdrawal, withdrawal state; alcohol, withdrawal; alcohol, Alcohol Withdrawal, Alcohol withdrawal syndrome, Alcohol withdrawal, Alcohol abstinence syndrome or symptoms, Alcohol withdrawal syndrome or symptoms
Czech Alkoholový odvykací syndrom
Hungarian Alkohol megvonásos szindróma
Dutch alcohol; abstinentieverschijnselen of -syndroom, alcohol; intoxicatie, onthoudingstoestand, alcohol; onthoudingssyndroom, alcohol; onthoudingstoestand, alcohol; onthouding, intoxicatie; alcohol, onthoudingstoestand, onthouding; alcohol, onthoudingstoestand; alcohol, syndroom; alcoholonthouding, alcoholonthoudingssyndroom
Portuguese Síndrome de privação de álcool
Spanish Síndrome de abstinencia alcohólica, síndrome de abstinencia del alcohol (trastorno), síndrome de abstinencia del alcohol
French Syndrome du sevrage de l'alcool
German Alkoholentzugssyndrom