What are the admitting orders and management principles for a patient presenting with alcohol withdrawal syndrome, including focused history and physical examination?

Management of Alcohol Withdrawal Syndrome: Admitting Orders and Principles

Indications for Hospital Admission

Admit patients with alcohol withdrawal syndrome to inpatient care if they have any of the following: significant AWS symptoms, history of withdrawal seizures or delirium tremens, high levels of recent drinking, co-occurring serious medical or psychiatric illness, or failure of outpatient treatment. 1

Focused History

Obtain the following critical historical elements:

• Alcohol use pattern: Quantity, frequency, duration of heavy drinking, and timing of last drink (AWS typically begins 6-24 hours after cessation) 1
• Previous withdrawal history: Prior seizures, delirium tremens, or complicated withdrawals requiring hospitalization 1
• Comorbid conditions: Liver disease, head trauma, respiratory failure, psychiatric illness, polysubstance abuse 1, 2
• Current symptoms: Tremor, sweating, tachycardia, anxiety, agitation, hallucinations, confusion, nausea/vomiting 1
• Nutritional status: Signs of thiamine deficiency or Wernicke-Korsakoff syndrome 1, 2

Focused Physical Examination

Assess for the following specific findings:

• Vital signs: Tachycardia, hypertension, hyperthermia, tachypnea (autonomic hyperactivity) 1
• Neurological exam: Tremor (especially hands), hyperreflexia, altered mental status, disorientation, seizure activity 1
• Mental status: Agitation, hallucinations (visual, tactile, auditory), delirium, fluctuating consciousness 1
• Signs of complications: Dehydration, fever, signs of infection, gastrointestinal bleeding, pancreatitis, hepatic encephalopathy 1
• Stigmata of chronic liver disease: Jaundice, ascites, spider angiomata, hepatomegaly 1
• Nutritional deficiencies: Ophthalmoplegia, ataxia, confusion (Wernicke's triad) 1

Admitting Orders

1. Monitoring Orders

• Vital signs every 1-2 hours initially, then every 4 hours once stable 1
• CIWA-Ar scoring every 1-4 hours (score >8 indicates moderate AWS requiring treatment; score ≥15 indicates severe AWS) 1, 3
• Continuous telemetry for patients with severe symptoms or cardiac risk factors 1
• Seizure precautions 1

2. Laboratory Orders

• Complete blood count, comprehensive metabolic panel
• Liver function tests (AST, ALT, bilirubin, albumin)
• Magnesium, phosphate
• Blood alcohol level
• Toxicology screen (to identify polysubstance use)
• Consider ammonia if hepatic encephalopathy suspected 1, 2

3. Pharmacological Orders

Thiamine (MUST be given BEFORE any glucose-containing IV fluids)

• Thiamine 100-300 mg IV/IM daily for prevention of Wernicke encephalopathy 1, 3
• Continue for 4-12 weeks for prevention; 12-24 weeks if Wernicke encephalopathy present 1
• Critical caveat: Administering glucose before thiamine can precipitate acute Wernicke encephalopathy 1, 3

Benzodiazepines (First-Line Treatment)

For most patients (without liver failure):

• Diazepam 5-10 mg PO/IV/IM every 6-8 hours (long-acting, preferred for seizure prevention) 1, 4
• Alternative: Chlordiazepoxide 25-100 mg PO every 4-6 hours 1

For patients with liver failure, advanced age, respiratory failure, obesity, or recent head trauma:

• Lorazepam 1-4 mg PO/IV/IM every 4-8 hours (starting dose 6-12 mg/day divided) 1, 3
• Lorazepam is safer because it doesn't require hepatic oxidation 1, 5

Dosing strategy: Use symptom-triggered regimen based on CIWA-Ar scores rather than fixed-dose schedule to prevent drug accumulation 1

Taper: Begin tapering after resolution of withdrawal symptoms; limit total benzodiazepine treatment to 10-14 days maximum to avoid dependence 1, 3

Adjunctive Medications (Use Only When Indicated)

• Haloperidol 0.5-5 mg PO/IM every 8-12 hours: Only for agitation or psychotic symptoms (hallucinations) NOT controlled by benzodiazepines alone 1, 3
• Carbamazepine 200 mg PO every 6-8 hours: Alternative for seizure prevention if benzodiazepines contraindicated 1, 3

4. Supportive Care Orders

• IV fluids: Normal saline or lactated Ringer's for hydration (give thiamine FIRST) 1
• Electrolyte replacement: Magnesium sulfate, potassium, phosphate as needed 1
• Multivitamin supplementation 1
• Comfortable, quiet environment with minimal stimulation 1
• Aspiration precautions if altered mental status 1

5. Consultation Orders

• Psychiatry consultation for evaluation, acute AWS management, and long-term abstinence planning 1, 3
• Consider addiction medicine or hepatology if significant liver disease present 3

Critical Medications to AVOID

Never prescribe the following in patients with alcoholic liver disease:

• Disulfiram: Risk of hepatotoxicity 3, 6, 5
• Naltrexone: Risk of hepatotoxicity 3, 6, 5

Common Pitfalls to Avoid

• Do NOT use CIWA-Ar alone for diagnosis of AWS, as high scores can occur in sepsis, hepatic encephalopathy, anxiety disorders, and severe pain 1
• Do NOT give glucose-containing IV fluids before thiamine administration 1, 3
• Do NOT use long-acting benzodiazepines (diazepam, chlordiazepoxide) in patients with liver failure—switch to lorazepam 1
• Do NOT continue benzodiazepines beyond 10-14 days due to risk of dependence 1, 3
• Do NOT use haloperidol as monotherapy—it is only adjunctive for symptoms not controlled by benzodiazepines 1

Treatment Goals

The primary goals are:

1. Prevent life-threatening complications (seizures, delirium tremens, cardiovascular collapse) 1
2. Provide symptomatic relief without oversedation 1
3. Establish foundation for long-term abstinence through psychiatric consultation and addiction treatment planning 1, 3