What medication should be administered to a patient with alcohol withdrawal symptoms, including tremors, sweating, and hallucinations?

Diazepam for Alcohol Withdrawal Management

The nurse should anticipate administering diazepam (Answer A), as long-acting benzodiazepines like diazepam are the gold standard first-line treatment for alcohol withdrawal symptoms including tremors, sweating, and hallucinations. 1, 2

Why Diazepam is the Correct Choice

Diazepam is specifically FDA-approved for acute alcohol withdrawal to provide symptomatic relief of acute agitation, tremor, impending or acute delirium tremens, and hallucinosis. 3

Pharmacological Advantages

• Diazepam provides superior seizure protection compared to other benzodiazepines due to its long-acting active metabolite (desmethyldiazepam), which creates a self-tapering effect that results in smoother withdrawal coverage and lower incidence of breakthrough symptoms. 1, 4
• The shortest time to peak effect among benzodiazepines allows for rapid symptom control and accurate titration to avoid over-sedation. 4
• Benzodiazepines are the only proven treatment to prevent seizures and reduce mortality from delirium tremens, making them essential for patients presenting with hallucinations and autonomic hyperactivity. 5, 6

Standard Dosing Protocol

• Initial dose: 10 mg IV or IM, followed by 5-10 mg every 3-4 hours as needed for acute alcohol withdrawal with tremors and hallucinations. 1, 3
• Administer slowly when using IV route—at least one minute per 5 mg given to minimize adverse effects. 3

Why Other Options Are Incorrect

Haloperidol (Option B)

• Neuroleptics like haloperidol increase the risk of seizures and are contraindicated as primary treatment for alcohol withdrawal. 6
• While they may be used as adjunctive therapy to control severe hallucinations, they should never replace benzodiazepines as first-line treatment. 7

Lithium (Option C)

• Lithium has no role in acute alcohol withdrawal management and is not indicated for this condition.

Morphine (Option D)

• Opioids like morphine do not address the underlying GABA-mediated pathophysiology of alcohol withdrawal and provide no protection against seizures or delirium tremens.

Critical Adjunctive Treatment

Thiamine 100-300 mg/day must be administered immediately to all patients with alcohol withdrawal to prevent Wernicke encephalopathy, which is a medical emergency. 1, 2, 5 This should be given before any glucose-containing fluids. 5

Monitoring Requirements

• Use the CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol-revised) scale to guide treatment intensity, with scores >8 indicating moderate withdrawal and scores ≥15 indicating severe withdrawal requiring more aggressive treatment. 1, 2
• Continuous monitoring of vital signs is crucial for detecting autonomic instability and assessing for complications including dehydration, electrolyte imbalance, and hepatic encephalopathy. 5

Common Pitfalls to Avoid

• Benzodiazepine treatment should not exceed 10-14 days to avoid the risk of dependence. 1, 2
• The common fear of over-sedation with diazepam compared to other benzodiazepines is unfounded and based on misunderstanding of its pharmacokinetics. 4
• Avoid intramuscular diazepam if possible, as its lipophilicity can result in slow absorption; if IM is the only route available, consider lorazepam instead. 4