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Alcohol Withdrawal
Richard K. Newman; Megan A. Stobart Gallagher; Anna E. Gomez.

Author Information
Last Update: November 13, 2021.

Continuing Education Activity

Alcohol withdrawal symptoms usually appear when an individual discontinues or reduces
alcohol intake after a period of prolonged consumption. In most cases, mild symptoms may start
to develop within hours of the last drink. This activity reviews the evaluation and management of
alcohol withdrawal and highlights the interprofessional team's role in the recognition and
management of this condition.

Objectives:

Identify the etiology of alcohol withdrawal.

Outline strategies for decreasing alcohol dependency in patients with alcohol withdrawal.

List the treatment options available for alcohol withdrawal.

Describe interprofessional team strategies for improving care coordination and

communication to improve outcomes in patients with alcohol withdrawal.

Access free multiple choice questions on this topic.

Introduction
Alcohol withdrawal symptoms occur when patients stop drinking or significantly decrease their
alcohol intake after long-term dependence. Withdrawal has a broad range of symptoms from
mild tremors to a condition called delirium tremens, which results in seizures and could progress
to death if not recognized and treated promptly.[1][2] The reported mortality rate for patients
who experience delirium tremens is anywhere from 1 to 5%.

Etiology
Ethanol is the primary alcohol ingested by chronic users. It is a central nervous system (CNS)
depressant that the body becomes reliant on with extended exposure to ethanol.  It does this by
inhibiting the excitatory portion (glutamate receptors) of the CNS and enhancing the inhibitory
portions (GABA receptors) of the CNS. When the depressant is stopped, the central nervous
system becomes overexcited as the inhibition is taken away. Thus, the body gets an excitatory
overload, which results in the symptoms of withdrawal.[3]

Epidemiology
Alcohol use disorder (AUD) per the DSM-IV is common, especially in the emergency
department, where about 40% of patients have AUD.[4] In patients coming into the ED with
trauma and a Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar)
score nearly 83% were of Male gender, and 43% were older than 55 years old. Of these patients
with trauma, nearly 52% of those showing AWS symptoms had a CIWA-Ar score >20, 24%
progressed to delirium tremens (DT).[5] Delirium tremens is fatal in nearly 15% of cases without
treatment and 1% in those who do receive treatment. 

Pathophysiology
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GABA (gamma-aminobutyric acid) is the major inhibitory neurotransmitter in the central

nervous center. GABA has particular binding sites available for ethanol, thus increasing the
inhibition of the central nervous system when present. Chronic ethanol exposure to GABA
creates constant inhibition or depressant effects on the brain. Ethanol also binds to glutamate,
which is one of the excitatory amino acids in the central nervous system. When it binds to
glutamate, it inhibits the excitation of the central nervous system, thus worsening the depression
of the brain. 

History and Physical

Alcohol withdrawal can range from very mild symptoms to a severe form, which is named
delirium tremens. The hallmark is autonomic dysfunction resulting from the excitation of the
central nervous system. Mild signs/symptoms can arise within six hours of alcohol cessation. If
symptoms do not progress to more severe symptoms within 24 to 48 hours, the patient will likely
recover. However, the time to presentation and range of symptoms can vary greatly depending on
the patient, their duration of alcohol dependence, and the volume typically ingested. Most cases
should be described by their severity of symptoms, not the time since their last drink. Noting the
time of their last drink is essential in any patient with an alcohol dependence history who may be
presenting with other complaints. You can help prevent withdrawal by staying on top of this!
Some features that may heighten your suspicion that a patient could suffer severe withdrawal
include a history of prior delirium tremens as well as a history of low platelets
(thrombocytopenia) or low potassium levels (hypokalemia).[6][7]

Mild symptoms can be elevated blood pressure, insomnia, tremulousness, hyperreflexia, anxiety,
gastrointestinal upset, headache, palpitations.

Moderate symptoms include hallucinations and alcohol withdrawal seizures (rum fits) that can
occur 12 to 24 hours after cessation of alcohol and are typically generalized in nature. There is a
3% incidence of status epilepticus in these patients. About 50% of patients who have had a
withdrawal seizure will progress to delirium tremens.

Delirium tremens is the most severe form of alcohol withdrawal, and its hallmark is that of an
altered sensorium with significant autonomic dysfunction and vital sign abnormalities. It
includes visual hallucinations, tachycardia, hypertension, hyperthermia, agitation, and
diaphoresis. Symptoms of delirium tremens can last up to seven days after alcohol cessation and
may last even longer.

These symptoms mimic those of withdrawal from long-term benzodiazepine or barbiturate use,
so important historical features to note when a patient presents with autonomic dysfunction
suspicious for a withdrawal syndrome should always include a medication list and social history.
Also, consider these risk factors for any patient presenting with seizures of unknown etiology.

Evaluation
The diagnosis of alcohol withdrawal can be made by taking an excellent history and performing
a thorough physical examination. It is a clinical diagnosis based on mild, moderate, or severe
symptoms. Patients with suspicion for alcohol withdrawal should be evaluated for other
underlying disease processes such as dehydration, infection, cardiac issues, electrolyte
abnormalities, gastrointestinal bleeding, and traumatic injury. Laboratory studies (electrolytes,
blood counts) may be drawn but will likely be nondiagnostic. Many chronic alcoholics will have
baseline ketoacidosis due to their poor nutritional status, and labs may show acidemia with
ketone production similar to a diabetic but with euglycemia or hypoglycemia due to lack of
glycogen stores in their liver.[8][9][10]

Assessment

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The Clinical Institute for Withdrawal Assessment for alcohol revised scale (CIWA-Ar) is a tool
used to assess the severity of alcohol withdrawal symptoms. The tool allows clinicians to
monitor for the signs and symptoms of withdrawal and determine who needs medical therapy.
The features that are used for the CIWA-Ar scale include the presence of:

Nausea and vomiting

Headache

Auditory disturbances

Agitation

Paroxysmal sweating

Visual disturbances

Tremor

Clouding of sensorium

Orientation

Anxiety

Some literature recommends checking an alcohol level at the time of onset of symptoms as
symptomatic patients while still having a positive alcohol level with symptoms of autonomic
dysfunction/withdrawal will have a higher morbidity/mortality, and their short-term prognosis
can be poor.

Patients with prolonged altered sensorium or significant renal abnormalities should receive an
evaluation for the potential ingestion of another toxic alcohol. Patients who become financially
strapped due to alcoholism could ingest other alcohols to become intoxicated. These can include
isopropyl alcohol, commonly known as rubbing alcohol, which can lead to acidemia without
ketosis as well as hemorrhagic gastritis. Ethylene glycol (antifreeze) ingestion can lead to an
altered sensorium, seizures, and severe renal dysfunction with acidemia that may require the
initiation of hemodialysis. Methanol is rarely ingested as an ethanol substitute but can result in
multisystem organ failure, blindness, and seizures.

Other common household substances can also contain a significant amount of alcohol if ingested
in large quantities, including mouthwash and cough syrup. Some of these items may also contain
a high content of salicylates or acetaminophen, so consider checking aspirin and acetaminophen
levels in patients presenting with alcohol withdrawal.

Treatment / Management
Patients should be kept calm in a controlled environment to try to reduce the risks of progression
from mild symptoms to hallucinations. With mild to moderate symptoms, patients should receive
supportive therapy in the form of intravenous rehydration, correction of electrolyte
abnormalities, and have comorbid conditions as listed above ruled out. Due to the risk of a
comorbid condition called Wernicke-Korsakoff syndrome, patients can also receive a “banana
bag” or cocktail of folate, thiamine, dextrose containing fluids, and a multivitamin.[11][12][13]

The hallmark of management for severe symptoms is the administration of long-acting

benzodiazepines. The most commonly used benzodiazepines are intravenous diazepam or
intravenous lorazepam for management. Patients with severe withdrawal symptoms may require
escalating doses and intensive care level monitoring. Early consultation with a toxicologist is
recommended to assist with aggressive management as these patients may require
benzodiazepine doses at a level higher than the practitioner is comfortable with to manage their
symptoms.
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While patients with mild symptoms can be managed as outpatients, the following patients should
be admitted:

Absence of support systems

Abnormal laboratory results

High risk of Delirium tremens

History of withdrawal seizures

Concomitant psychiatric problems

Abuse of other substances

Suicidal ideations

Withdrawal seizures can typically be managed with benzodiazepines but may require adjunct
therapy with phenytoin, barbiturates, and may even require intubation and sedation with
propofol, ketamine, or in the most severe cases, dexmedetomidine.

Oral chlordiazepoxide and oxazepam are very commonly used for the prevention of withdrawal
symptoms. Other drugs often used to manage symptoms include neuroleptics, anticonvulsants
like carbamazepine, and valproic acid.

Propofol is used to manage refractory cases of delirium tremens, and baclofen can be used to
treat muscle spasms.

Toxic alcohol co-ingestion should be managed with the assistance of a toxicologist.

Differential Diagnosis

Thyrotoxicosis

Stimulant drug abuse

Status epilepticus

CNS infection

Withdrawal from sedative-hypnotics

Essential tremors

Prognosis
The prognosis often depends on the severity of alcohol withdrawal syndrome. Clinical
outcomes such as length of hospital length of stay, length of time in the ICU, and alcohol
withdrawal syndrome complications often show significant differences based on alcohol
withdrawal syndrome severity and are worse with more severe manifestations of alcohol
withdrawal syndrome. Mortality is also greater in patients who progress to delirium tremens.

Complications
Complications that can accompany alcohol withdrawal syndrome include[14]:

Delirium tremens

Seizures

Wernicke-Korsakoff syndrome

Anxiety

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Depression

Sleep disturbances

Hallucinations

Cardiovascular complications

Postoperative and Rehabilitation Care

Alcoholics tend to have nutritional deficiencies and thus should be provided with folic and
thiamine supplements. Some patients may benefit from magnesium supplements.

Deterrence and Patient Education

Patients need to understand that successful treatment of alcohol withdrawal syndrome is only the
initial step that must lead to long-term abstinence to be successful. Abstinence is not likely
unless the patient enrolls in a long-term treatment program. These programs can include
individual counseling, group meetings, and long-term medications to reduce the risk of relapse.
[15]

Pearls and Other Issues

Patients with a history of alcohol dependence may have confounding social or underlying
psychiatric issues that one should also be aware of once they are stabilized. They will likely
require a multidisciplinary approach before discharge.

Enhancing Healthcare Team Outcomes

Alcohol withdrawal symptoms usually appear when the individual discontinues or reduces
alcohol intake after a period of prolonged consumption. However, healthcare workers should be
aware that alcohol withdrawal symptoms can be severe and lead to death. In all cases, the
management of alcohol withdrawal is monitored and managed by an interprofessional team to
ensure good outcomes.

Alcohol withdrawal can be managed both as an inpatient or outpatient. In each case, close
monitoring is essential as the symptoms can suddenly become severe.

In most cases, mild symptoms may start to develop within hours after the last drink, and if left
untreated, can progress and become more severe. Because chronic alcohol use is widespread in
society, all healthcare workers, including the nurse and pharmacist, should be familiar with the
symptoms of alcohol withdrawal and its management. Nurses monitoring alcoholic patients
should be familiar with signs and symptoms of alcohol withdrawal and communicate to the
interprofessional team if there are any deviations from normal. In most cases, the symptoms are
autonomic. For those who develop delirium tremens, monitoring in a quiet room is
recommended. 

Today, pharmacotherapy is often used to manage the symptoms of alcohol withdrawal. However,
if the symptoms are severe and pharmacological treatment is required, the patient should be
referred to an internist or an alcohol treatment specialist. Prompt referral and treatment can help
lower the morbidity of alcohol withdrawal symptoms and may even be lifesaving.[16][17]

After treatment, the patient should be referred to AA and urged to abstain from alcohol. For
patients without support, a social worker should be involved to help facilitate addiction
rehabilitation. 

Outcomes

Today the outcomes for most patients with alcohol withdrawal are good, but for those who
develop delirium tremens, the findings are less optimal. Despite optimal treatment, the condition
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is associated with mortality rates of 1 to 5%.[18] [Level 5]

Review Questions

Access free multiple choice questions on this topic.

Comment on this article.

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