Last reviewed: March 2026
Contents
MDM Templates
Alcohol Withdrawal — Mild (Discharge)
Patient presents with symptoms consistent with alcohol withdrawal after recent reduction in or cessation of chronic alcohol use. Symptoms include anxiety, nausea, tremor, tachycardia, and diaphoresis. Alert, oriented, no hallucinations, no confusion. No history of withdrawal seizures, DTs, or ICU admissions for withdrawal.
Presentation consistent with mild alcohol withdrawal. Not consistent with infectious etiology, thyrotoxicosis, co-ingestion toxidrome, primary psychiatric disorder, or severe metabolic derangement (hypoglycemia, AKA, electrolyte abnormality). Symptoms controlled with initial benzodiazepine dosing and improving on serial exams.[1]
Plan: Symptom-triggered benzodiazepines in ED with reassessment. Patient ambulating without difficulty and tolerating oral intake after treatment. Discharge with chlordiazepoxide taper (50 mg TID x 2 days, then 25 mg TID x 2 days, then 25 mg PRN x 2 days). Thiamine 100 mg daily, folate 1 mg daily. PCP follow-up within 1 week. Substance use resources provided. Return for worsening tremor, confusion, hallucinations, seizure, or fever.
Alcohol Withdrawal — Moderate (Admit)
Patient presents with moderate alcohol withdrawal not adequately controlled after 3-4 doses of benzodiazepines in the ED. Persistent tachycardia, tremor, diaphoresis, and agitation despite treatment. May have hallucinations but remains oriented.
Failure to control symptoms with initial ED dosing raises concern for progression to severe withdrawal or DTs. History of prior complicated withdrawal (seizures, DTs, ICU admissions) further elevates risk. Not consistent with co-ingestion, sepsis, or thyrotoxicosis given clinical trajectory and workup.[1]
Plan: Continued symptom-triggered benzodiazepines. Thiamine, magnesium, folate repleted. Admit for continued monitoring and treatment. Escalate to ICU if benzodiazepine requirements increasing or phenobarbital required.
Alcohol Withdrawal Seizure
Patient presents with generalized tonic-clonic seizure in the context of recent alcohol cessation or reduction. Seizure was self-limited. Patient returning to baseline. No focal deficits, no signs of meningismus, no head trauma.
Presentation consistent with alcohol withdrawal seizure, which typically occurs 12-48 hours after last drink. Alcohol withdrawal seizures are the second most common cause of status epilepticus in adults. History of prior withdrawal seizures significantly increases recurrence risk. Not consistent with other seizure etiology (no focal deficits, no fever, improving mental status).[2]
Plan: Benzodiazepines for seizure prophylaxis and withdrawal management. Admit to monitored setting given high risk of progression to DTs (DTs occur in 30% of patients who seize from withdrawal). Defer LP, neurology consultation, and advanced imaging to inpatient team unless clinical picture changes.
If recurrent seizures or status epilepticus: Consider neuroprotective intubation with propofol. Phenobarbital loading. ICU admission.
Delirium Tremens
Patient presents with confusion, agitation, diaphoresis, tachycardia, hypertension, and tremor in the setting of recent alcohol cessation. Hallucinations present (visual, tactile, or auditory). Disoriented. This clinical picture is consistent with delirium tremens.
DTs represent the most severe and life-threatening form of alcohol withdrawal, with mortality of 5-15% if untreated. Typically onset 48-96 hours after last drink. Presentation less consistent with delirium from other cause, acute psychosis, infectious etiology, ICH, NMS, serotonin syndrome, thyrotoxicosis, or hepatic encephalopathy.[1]
Plan: Aggressive benzodiazepine dosing. Thiamine 500 mg IV, magnesium 2 g IV, folate, multivitamin. Escalate to phenobarbital if refractory. Admit to ICU. Consider CT head and LP to exclude alternative diagnoses if clinical picture warrants.
Clinical Education
Withdrawal Timeline
| Time After Last Drink | Syndrome | Features |
| 6-12 hours | Minor withdrawal | Tremor, anxiety, nausea, insomnia, tachycardia |
| 12-24 hours | Alcoholic hallucinosis | Visual/auditory/tactile hallucinations with intact sensorium |
| 12-48 hours | Withdrawal seizures | Brief generalized tonic-clonic, may cluster |
| 48-96 hours | Delirium tremens | Confusion, agitation, autonomic instability, hallucinations, fever |
These timelines overlap and are not strictly sequential. A patient can progress directly to DTs without going through earlier stages. The timeline is a guide, not a guarantee — clinical assessment trumps the clock.[1]
Assessment and Risk Stratification
The CIWA-Ar score is widely used but has significant limitations. It requires a cooperative, communicative patient and cannot be used in intubated, obtunded, or delirious patients. It is useful for trending symptom severity but should not replace clinical judgment.[1]
Risk factors for severe or complicated withdrawal: prior DTs, prior withdrawal seizures, prior ICU admission for withdrawal, heavy daily intake (>10 drinks/day), prolonged daily use, age >65, concurrent medical illness, abnormal liver function, and prior failed outpatient detox.
Alcoholic hallucinosis is NOT delirium tremens. In hallucinosis, the patient has hallucinations but remains oriented and has intact sensorium. In DTs, the patient is globally confused with autonomic instability. This distinction matters because hallucinosis alone does not mandate ICU admission.
Benzodiazepine Protocols
Symptom-triggered dosing is superior to fixed-schedule dosing. It results in less total benzodiazepine use, shorter treatment duration, and fewer complications. Treat to effect — there is no maximum dose.[1]
Typical ED dosing: Diazepam 10-20 mg IV q10-15 min or lorazepam 2-4 mg IV q15-20 min until symptoms controlled. Reassess after each dose. Goal is calm, cooperative patient with mild tremor or no tremor.
Chlordiazepoxide taper for discharge (mild withdrawal, low-risk patient): 50 mg TID x 2 days, then 25 mg TID x 2 days, then 25 mg PRN x 2 days. Total 21 capsules. Only appropriate for patients with no history of complicated withdrawal, reliable follow-up, and no concerning co-morbidities.
Diazepam’s long half-life provides auto-taper via active metabolites (desmethyldiazepam, t1/2 ~100 hours). This can be advantageous for gradual self-tapering but disadvantageous in hepatic impairment. Lorazepam is preferred in liver disease (no hepatic metabolism).
Phenobarbital Protocol
Phenobarbital is increasingly used as first-line or adjunct for alcohol withdrawal. It acts on both GABA-A and glutamate pathways, providing more complete neuronal inhibition than benzodiazepines alone. Its long half-life (50-100 hours) provides smooth auto-taper without outpatient prescriptions.[2]
Loading protocol: Phenobarbital 10 mg/kg IV over 30 minutes (common starting dose ~260 mg for 65 kg patient). May repeat 130-260 mg IV q15-30 min PRN. Monitor for respiratory depression. Some protocols add lorazepam 2 mg concurrently with the initial load.
Single-dose ED protocol (Highland model): Phenobarbital 260 mg IV (~4 mg/kg) plus lorazepam 2 mg IV. Reassess at 1 hour. Additional phenobarbital 130 mg PRN q1h. Discharge without benzodiazepine taper (phenobarbital’s long half-life provides the taper). Studies show no increase in respiratory depression or prolonged drowsiness.[2]
Refractory Withdrawal
Refractory withdrawal is defined as persistent symptoms despite high-dose benzodiazepines. These patients require ICU admission and escalation of therapy. In severe chronic alcohol use, GABA receptor downregulation makes benzodiazepines progressively less effective.[3]
Escalation options: Phenobarbital (if not already started). Propofol infusion (provides GABA agonism and NMDA antagonism). Ketamine 0.2 mg/kg/hr as adjunct (NMDA antagonism addresses glutamate upregulation). Dexmedetomidine as adjunct for sympatholytic effect (does not treat seizure risk).
Intubation threshold: Protect the airway if escalating to propofol infusion. Consider neuroprotective intubation for recurrent seizures. Propofol provides both sedation and seizure suppression.
Disposition
Discharge: Mild withdrawal controlled with 1-3 doses of benzodiazepines. No history of complicated withdrawal. Reliable follow-up, safe living situation. Prescribe chlordiazepoxide taper or utilize phenobarbital single-dose protocol. Thiamine and folate. Substance use resources. PCP follow-up within 1 week.
Admit (floor/telemetry): Moderate withdrawal requiring >3-4 doses of benzodiazepines. Alcoholic hallucinosis. Significant comorbidities. Unreliable follow-up or prior failed outpatient detox.
Admit (ICU): DTs. Withdrawal seizure (30% progress to DTs). Refractory withdrawal despite aggressive ED dosing. Hemodynamic instability. Need for phenobarbital loading or continuous infusions.
References
- Long D, Long B, Koyfman A. The emergency medicine management of severe alcohol withdrawal. Am J Emerg Med. 2017;35(7):1005-1011. PubMed
- Rosenson J, Clements C, Simon B, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013;44(3):592-598. PubMed
- Hack JB, Hoffmann RS, Nelson LS. Resistant alcohol withdrawal: does an unexpectedly large sedative requirement identify these patients early? J Med Toxicol. 2006;2(2):55-60. PubMed
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