What are the recommended admission orders for a patient with severe alcohol intoxication or withdrawal?

Admission Orders for Severe Alcohol Intoxication or Withdrawal

For patients with severe alcohol withdrawal, admit to the hospital for close monitoring, initiate benzodiazepines as first-line treatment (diazepam 10 mg IV initially, then 5-10 mg every 3-4 hours as needed), and immediately administer thiamine 100-300 mg before any dextrose-containing fluids. 1, 2, 3

Admission Criteria

Admit patients with any of the following:

• Severe withdrawal symptoms including delirium, seizures, or delirium tremens 4, 1, 2
• Concurrent serious physical or psychiatric disorders 4, 1
• History of complicated withdrawal or inadequate social support 1, 2
• Malnutrition or suspected Wernicke's encephalopathy 4, 1
• Persistent abnormal vital signs despite initial treatment 5

Initial Orders Upon Admission

Monitoring

• Continuous telemetry and vital signs every 1-2 hours for first 24 hours, focusing on autonomic instability (tachycardia, hypertension, hyperthermia, diaphoresis) 1, 2, 6
• Symptoms typically peak at 3-5 days post-cessation, requiring vigilant monitoring throughout this period 2, 6

Laboratory Studies

• Complete blood count (CBC) 6
• Complete metabolic panel (CMP) including glucose, electrolytes, renal function 6
• Magnesium level 6
• Liver function tests 4
• Blood alcohol level 6
• Urine drug screen 6

Imaging

• CT head if altered mental status, history of head trauma, or focal neurological findings 6
• Avoid iodinated contrast if possible due to increased acute kidney injury risk 4

Pharmacological Management

First-Line: Benzodiazepines

For standard patients without contraindications:

• Diazepam 10 mg IV initially, then 5-10 mg IV every 3-4 hours as needed for symptom control 4, 1, 3
• Maximum 30 mg in first hour if severe symptoms, though some patients may require escalating doses 3, 5
• Long-acting benzodiazepines (diazepam, chlordiazepoxide) are preferred for most patients due to superior seizure and delirium tremens prevention through gradual self-tapering 1, 2, 7

For high-risk patients (hepatic dysfunction, advanced age, respiratory compromise, obesity, recent head trauma):

• Lorazepam 6-12 mg/day IV, divided into doses every 4-6 hours 1, 2, 7
• Lorazepam is safer in these populations due to intermediate duration and lack of active metabolites 1, 7

Critical benzodiazepine principles:

• Limit treatment to 10-14 days maximum to prevent iatrogenic dependence 1, 2, 7
• Dispense in small quantities or supervise each dose to reduce misuse risk 4, 2
• Facilities for respiratory assistance must be readily available when using IV benzodiazepines 3

Mandatory Thiamine Administration

All patients require thiamine supplementation:

• Thiamine 100-300 mg IV or oral daily for standard cases 4, 1, 2, 7
• Thiamine must be given BEFORE any dextrose-containing IV fluids to prevent precipitating acute Wernicke's encephalopathy 7, 6
• Administering glucose before thiamine can cause irreversible neurological damage 7

For high-risk patients (malnourished, severe withdrawal, suspected Wernicke's encephalopathy):

• Parenteral thiamine 500 mg IV three times daily 4, 1, 2, 7
• This is a medical emergency requiring immediate treatment; delays cause irreversible damage 2, 7

Management of Specific Complications

Seizures:

• Benzodiazepines are the only necessary treatment for alcohol withdrawal seizures 1, 7, 8
• Do NOT use anticonvulsants (phenytoin, carbamazepine) to prevent further withdrawal seizures—they are ineffective and may worsen outcomes 4, 1, 2, 7
• If seizures occur, give diazepam 5-10 mg IV, may repeat every 10-15 minutes up to maximum 30 mg 3

Delirium Tremens:

• Continue aggressive benzodiazepine therapy 4, 1, 8
• If refractory to adequate benzodiazepine doses, add haloperidol as adjunct only 4, 1, 2, 7
• Never use antipsychotics as monotherapy—they lower seizure threshold and worsen outcomes 4, 1, 2, 7
• Mortality can reach 50% without treatment but drops below 3% with appropriate management 8

Resistant alcohol withdrawal (requiring >50 mg diazepam in first hour):

• These patients may require barbiturates, intubation, and ICU-level care 5
• Consider early ICU consultation if escalating benzodiazepine requirements 5

Supportive Care Orders

Fluid and Electrolyte Management

• IV normal saline at maintenance rate (avoid excessive fluid administration in patients with heart disease due to pulmonary edema risk) 8
• Correct electrolyte abnormalities, particularly hypokalemia, hypomagnesemia, hypophosphatemia 6
• Magnesium sulfate 2 g IV if hypomagnesemia present 6

Nutritional Support

• Diet with 1-1.5 g protein and 30-40 kcal/kg body weight daily 4
• If unable to eat due to anorexia or altered mental status, consider feeding tube for enteral nutrition 4
• Parenteral nutrition alone is inadequate 4

Evaluate for Common Comorbidities

• Dehydration 1, 7
• Gastrointestinal bleeding 1, 7
• Pancreatitis 1, 7
• Infection (obtain blood, urine, and ascites cultures even without fever) 4
• Head trauma 1, 7

Consultations

• Psychiatry consultation for evaluation, acute management, and long-term abstinence planning 1, 2, 7
• Critical care consultation if resistant withdrawal or delirium tremens 5

Medications to Avoid

• Antipsychotics as monotherapy (increase seizure risk) 4, 1, 2, 7
• Anticonvulsants for seizure prevention (ineffective for withdrawal seizures) 4, 1, 2, 7
• Beta-blockers (increase hallucination risk) 8
• Clonidine (increases nightmare risk) 8
• Nephrotoxic drugs including diuretics (avoid or use sparingly due to acute kidney injury risk) 4

Disposition Planning

• ICU admission if delirium tremens, resistant withdrawal requiring >50 mg diazepam in first hour, or need for intubation 5
• Telemetry floor admission for severe withdrawal without delirium tremens 1, 2
• After successful withdrawal, offer relapse prevention with acamprosate, disulfiram, or naltrexone based on patient preference and motivation 4, 1
• Encourage engagement with Alcoholics Anonymous or similar mutual help groups 4

Critical Pitfalls to Avoid

• Never delay thiamine when Wernicke's encephalopathy is suspected—irreversible damage occurs rapidly 2, 7
• Never give dextrose before thiamine—this precipitates acute Wernicke's encephalopathy 7, 6
• Never use anticonvulsants alone for withdrawal seizures—benzodiazepines are required 1, 2, 7
• Never exceed 10-14 days of benzodiazepine therapy—this creates iatrogenic dependence 1, 2, 7
• Never use antipsychotics as stand-alone treatment—they worsen seizure risk 4, 1, 2, 7