What are the next steps for a patient experiencing dizziness after stopping heavy alcohol consumption?

Evaluation and Management of Dizziness in Former Heavy Drinker

This patient requires immediate assessment for alcohol withdrawal syndrome (AWS), which can present with dizziness as part of autonomic dysfunction and can progress to life-threatening complications including seizures and delirium tremens within 48-72 hours of alcohol cessation. 1, 2

Immediate Assessment

Determine Timing and Severity of Withdrawal

• Establish when the patient last consumed alcohol - AWS follows a predictable temporal sequence: mild symptoms begin within 6-24 hours, seizures occur within 48 hours, and delirium tremens peaks at 3-5 days after the last drink 2
• Use the CIWA-Ar scale immediately to assess withdrawal severity - a score >8 indicates moderate AWS requiring intervention, while ≥15 indicates severe AWS requiring immediate treatment 1, 3
• Look specifically for: tremors, hyperreflexia, tachycardia, hypertension, sweating, nausea, anxiety, and altered mental status 2, 3

Rule Out Concurrent Medical Emergencies

• Check bedside glucose immediately - hypoglycemia is the most common metabolic cause of altered mental status and dizziness in this population and may be unsuspected on clinical examination 4
• Assess for infection - bacterial infections commonly precipitate AWS and worsen outcomes, though fever may be absent and white blood cell count unreliable 4
• Evaluate for head trauma - patients with alcohol use disorder have higher rates of intracranial lesions, particularly if there are focal neurologic deficits, persistent altered mental status, or recent trauma 4

Acute Management Based on Assessment

If AWS is Present (CIWA-Ar >8)

• Initiate benzodiazepines immediately - long-acting agents (diazepam, chlordiazepoxide) provide superior seizure protection and prevent progression to delirium tremens 1, 2, 3
• Use symptom-triggered dosing rather than fixed schedules to prevent drug accumulation, limiting treatment to 7-10 days 3
• Administer thiamine 100-500 mg IV immediately before any glucose-containing fluids to prevent Wernicke encephalopathy 2, 3

If Liver Disease is Present or Suspected

• Switch to short or intermediate-acting benzodiazepines (lorazepam, oxazepam) which are safer in hepatic dysfunction 3
• Exercise caution with medication dosing as liver disease increases risk of severe withdrawal and adverse medication effects 4, 1

Alternative Causes of Dizziness to Consider

Autonomic Dysfunction from Chronic Alcohol Use

• Recognize that 16-73% of chronic alcohol abusers develop autonomic dysfunction, which commonly manifests as postural dizziness due to orthostatic hypotension 5
• This improves with abstinence but may take time to resolve 5

Medication-Related Dizziness

• If the patient is on naltrexone for alcohol dependence, dizziness is a known side effect occurring at the standard 50 mg daily dose 6

Critical Pitfalls to Avoid

• Do not assume dizziness is benign - failure to recognize early AWS signs leads to rapid progression to seizures (within 48 hours) and delirium tremens (peak at 3-5 days), which carry significant mortality risk 1, 2
• Do not delay benzodiazepines - they should be initiated early (within 6-24 hours) to prevent progression, not just to treat established severe withdrawal 2
• Do not give glucose before thiamine - this can precipitate Wernicke encephalopathy 2
• Do not assume alcohol withdrawal seizures require anticonvulsants - they represent a rebound phenomenon with lowered seizure threshold and are prevented by benzodiazepines, not traditional anticonvulsants 2

Monitoring Requirements

• Close observation for 48-72 hours minimum as this is the highest-risk period for seizures and progression to delirium tremens 2
• Serial CIWA-Ar assessments to guide symptom-triggered benzodiazepine dosing 3
• Monitor vital signs closely for autonomic hyperactivity (tachycardia, hypertension) which indicates worsening withdrawal 2, 3