Signs and Symptoms of Alcohol Withdrawal
Alcohol withdrawal syndrome presents with a predictable timeline and constellation of symptoms beginning 6-24 hours after cessation, including autonomic hyperactivity (tremor, tachycardia, sweating), gastrointestinal symptoms (nausea, vomiting), and in severe cases, seizures, hallucinations, and delirium tremens that typically peak at 3-5 days. 1
Timeline and Clinical Presentation
Early Symptoms (6-24 hours)
- Autonomic nervous system activation manifests as tachycardia, hypertension, sweating, and hand tremor 1
- Gastrointestinal symptoms including nausea and vomiting are common early manifestations 1
- Anxiety, agitation, and insomnia develop as the withdrawal progresses 2
Intermediate Phase (24-48 hours)
- Alcohol withdrawal seizures occur as a rebound phenomenon due to lowered seizure threshold, typically appearing within 48 hours of cessation 1, 2
- These seizures are generalized without focal features and may occur singly or in brief clusters 2
- Hallucinations (visual, auditory, or tactile) can develop during this period 1, 2
Severe Complications (48-72 hours, peak 3-5 days)
- Delirium tremens represents the most severe form, characterized by:
- Symptoms typically peak at 3-5 days after cessation and can be fatal without treatment 1, 3
Critical Assessment Requirements
Vital Signs Monitoring
- Frequent monitoring is essential for detecting autonomic instability including tachycardia, hypertension, fever, and sweating 1, 3
- Continuous monitoring is crucial in severe cases to assess for life-threatening complications 3
Dangerous Comorbidities to Evaluate
- Metabolic complications: dehydration, electrolyte imbalance (especially magnesium depletion), renal failure 1, 3
- Neurological complications: head trauma, seizures, Wernicke encephalopathy 1, 3
- Gastrointestinal complications: bleeding, pancreatitis 1
- Hepatic complications: liver failure, hepatic encephalopathy 1, 3
- Infectious complications: sepsis, meningitis 2
Risk Factors for Severe Withdrawal
- History of chronic heavy drinking (>80 g/day for ≥10 years) 3
- Previous withdrawal seizures or delirium tremens 4
- Concurrent serious medical or psychiatric illness 1, 3
- Underlying alcoholic liver disease increases risk of hepatic encephalopathy 3
Management Approach
Pharmacological Treatment
- Benzodiazepines are first-line therapy and the only proven treatment to prevent seizures and reduce mortality from delirium tremens 1, 3, 5
- Long-acting benzodiazepines (chlordiazepoxide 50-100 mg initially, then 25-100 mg every 4-6 hours; or diazepam 5-10 mg every 6-8 hours) provide superior seizure protection 1, 6, 7
- Switch to lorazepam (6-12 mg/day) in patients with severe liver failure, advanced age, obesity, recent head trauma, or respiratory failure 1, 7
Essential Adjunctive Treatment
- Thiamine 100-300 mg/day must be administered BEFORE any glucose-containing IV fluids to prevent precipitating Wernicke encephalopathy 1, 3, 7
- Continue thiamine for 2-3 months following resolution of withdrawal symptoms 1, 3
Supportive Care
- Fluid and electrolyte replacement with particular attention to magnesium levels, which are commonly depleted 3, 7
- Provide a comfortable, reassuring environment 7
Critical Pitfalls to Avoid
- Do NOT use anticonvulsants alone for alcohol withdrawal seizures—these are rebound phenomena requiring benzodiazepines, not traditional antiepileptic drugs 1, 6
- Never administer glucose before thiamine, as this can precipitate acute Wernicke encephalopathy 3, 6
- Do NOT continue benzodiazepines beyond 10-14 days due to abuse potential 3, 7
- Neuroleptics should not be used as monotherapy as they increase seizure risk 4, 8
Indications for Inpatient Treatment
- Mandatory admission for serious complications including delirium tremens, withdrawal seizures, or altered mental status 1, 3
- Admit patients with: significant withdrawal symptoms (vomiting, tremor), co-occurring serious medical or psychiatric illness, history of severe withdrawal, or failure of outpatient treatment 1, 7