What is the recommended management of acute alcohol withdrawal in an adult poly‑trauma patient?

Management of Acute Alcohol Withdrawal in Polytrauma Patients

Benzodiazepines are the mandatory first-line therapy for acute alcohol withdrawal in polytrauma patients, being the only proven treatment that prevents seizures and reduces mortality from delirium tremens, with thiamine administered intravenously before any glucose-containing fluids to prevent Wernicke encephalopathy. 1

Immediate Assessment and Stabilization

Critical First Actions (Within Minutes)

• Administer thiamine 100-500 mg IV immediately before any glucose administration to prevent precipitating acute Wernicke encephalopathy in all polytrauma patients with suspected alcohol dependence. 1, 2
• Assess vital signs for autonomic instability including tachycardia, hypertension, fever, and sweating—these indicate more severe withdrawal requiring aggressive treatment. 1
• Evaluate for dangerous complications specific to polytrauma: hemorrhagic shock, traumatic brain injury, dehydration, electrolyte imbalance (especially magnesium), infection, and hepatic encephalopathy. 1

Special Considerations in Polytrauma

• In polytrauma patients with traumatic brain injury (TBI), the challenge is balancing hemorrhage control (which may require permissive hypotension) against preventing cerebral secondary damage from hypotension. 3
• Exsanguination is the most frequent cause of early death in trauma, but TBI is the most common cause of delayed mortality—both must be addressed simultaneously. 3

Pharmacological Management Algorithm

First-Line Benzodiazepine Selection

For most polytrauma patients without hepatic dysfunction or severe TBI:

• Diazepam 10 mg IV initially, then 5-10 mg every 3-4 hours as needed for severe withdrawal with altered consciousness. 1, 4
• Long-acting benzodiazepines like diazepam provide superior seizure protection due to self-tapering active metabolites. 1, 5
• Maximum 30 mg in acute management; may repeat therapy in 2-4 hours if necessary, considering residual active metabolites. 4

For polytrauma patients with hepatic dysfunction, elderly patients, or those with respiratory compromise/head trauma:

• Switch to lorazepam 2-4 mg IV for acute management, then 6-12 mg/day in divided doses. 1, 5
• Lorazepam has shorter half-life and minimal hepatic metabolism, reducing risk of dose-stacking in liver disease. 1
• Over 70% of cirrhotic patients may not require benzodiazepines at all—use symptom-triggered dosing only when Clinical Institute Withdrawal Assessment (CIWA-Ar) score ≥8. 1, 2

Emerging Evidence: Phenobarbital in Trauma Populations

• Recent trauma-specific data (2023-2024) demonstrate that phenobarbital-based protocols reduce AWS-related complications from 33% to 17% and decrease benzodiazepine requirements by more than 50% without increasing adverse events. 6, 7
• Phenobarbital prevented alcohol withdrawal delirium entirely in trauma patients (0% vs 48.2% with benzodiazepines alone) with no medication-related adverse events. 8
• Consider phenobarbital as adjunctive or alternative therapy in polytrauma patients, particularly those with TBI or rib fractures where benzodiazepine-related sedation poses additional risk. 6, 7, 8

Essential Supportive Care

Thiamine Protocol

• Continue thiamine 100-300 mg/day throughout withdrawal and for 2-3 months after resolution to support neurologic recovery and prevent Wernicke-Korsakoff syndrome. 1, 2
• For established Wernicke encephalopathy: 100-500 mg/day IV for 12-24 weeks. 2

Fluid and Electrolyte Management

• Provide aggressive fluid replacement with careful attention to magnesium supplementation—magnesium is commonly depleted in chronic alcohol use and essential for withdrawal management. 1, 5
• Monitor for dehydration, electrolyte imbalance, and metabolic derangements that can complicate both trauma and withdrawal. 1

Continuous Monitoring Requirements

• Frequent vital-sign monitoring for autonomic instability (tachycardia, hypertension, hyperthermia, sweating). 1, 2
• Assess for trauma-specific complications: ongoing hemorrhage, evolving TBI, infection (pneumonia, wound infections), gastrointestinal bleeding, and pancreatitis. 1, 2

Management of Specific Complications

Withdrawal Seizures

• Benzodiazepines are the only effective treatment for alcohol withdrawal seizures—do not use anticonvulsants (phenytoin, carbamazepine) for seizure prevention as they are ineffective and may worsen outcomes. 1, 5
• After a withdrawal seizure: continue symptom-triggered benzodiazepine therapy; anticonvulsants have no role in post-seizure prophylaxis. 5

Delirium Tremens (48-72 Hours Post-Cessation)

• Escalate benzodiazepine dosing aggressively for severe autonomic instability, confusion, and hallucinations. 1
• Haloperidol 0.5-5 mg may be added only as adjunctive therapy to adequate benzodiazepine regimens—never use antipsychotics as monotherapy as they lower seizure threshold and worsen outcomes. 1, 2

Refractory Severe Withdrawal

• For benzodiazepine-refractory cases in ICU settings: phenobarbital or propofol can be used as second-line sedative agents. 1
• Dexmedetomidine serves as adjunctive therapy only for severe cases but does not prevent seizures or delirium tremens—benzodiazepines remain mandatory. 1

Duration and Tapering

• Limit total benzodiazepine therapy to maximum 10-14 days to prevent iatrogenic dependence. 1, 2
• Begin taper after approximately 96 hours (day 4) when acute symptoms improve—reduce daily dose by 25% every 2-3 days for long-acting agents. 1
• Never discontinue benzodiazepines abruptly; always taper gradually to avoid rebound withdrawal. 1
• Dispense benzodiazepines in small quantities or supervise each dose to minimize misuse risk. 1, 2

Critical Pitfalls to Avoid

• Never administer glucose-containing IV fluids before thiamine—this can precipitate acute Wernicke encephalopathy. 1, 2
• Never rely on anticonvulsants alone for seizure prevention—benzodiazepines are mandatory. 1, 5
• Never use antipsychotics as monotherapy—they increase seizure risk and worsen outcomes. 1, 2
• Do not assume all cirrhotic trauma patients require benzodiazepines—employ symptom-triggered dosing only when CIWA-Ar ≥8. 1
• Do not extend benzodiazepine therapy beyond 14 days or discontinue abruptly—always taper. 1

Post-Acute Management

Mandatory Psychiatric Consultation

• Psychiatric consultation is required after stabilization for comprehensive evaluation of alcohol use disorder severity, ongoing treatment planning, and long-term abstinence strategies. 1, 2

Relapse-Prevention Pharmacotherapy (After Withdrawal Completion)

• Acamprosate (≈2 g/day for patients ≥60 kg)—safe in liver disease, reduces craving. 1, 2
• Baclofen (up to 80 mg/day)—the only medication with proven safety in cirrhotic patients. 1, 2
• Naltrexone is contraindicated in alcoholic liver disease due to hepatotoxicity risk. 1, 2
• Disulfiram is contraindicated in severe alcoholic liver disease due to hepatotoxicity. 1, 2
• Consider topiramate or other agents as alternatives. 1

Psychosocial Support

• Encourage engagement with mutual-help groups such as Alcoholics Anonymous to sustain recovery. 1, 2