Alcohol Withdrawal


Main Concepts:

Notable Features:

High Yield:



Alcohol withdrawal symptoms develop within 96 hours of cessation, and include:

  1. 6 - 24 hours - mild withdrawal

    1. Anxiety, insomnia, tremors, diaphoresis, palpitations, GI upset, and intact orientation

  2. 12 - 48 hours - seizures

    1. Single or multiple generalized tonic-clonic

  3. 12 - 48 hours - alcoholic hallucinosis

    1. Visual, auditory, or tactile

    2. Intact orientation

    3. Stable vital signs

  4. 48 - 96 hours - delirium tremens

    1. Altered sensorium: confusion, agitation, hallucinations

    2. Autonomic instability : fever, tachycardia, hypertension, diaphoresis



Look for:

  • Seizures, diaphoresis, tremulousness, and elevated pulse and BP (autonomic instability)

  • 2:1 AST:ALT ratio

Alcohol withdrawal symptoms typically peak on the second day following cessation. Seizures are most likely to occur within 12 - 48 hours.

As alcohol use may not be reported by patients admitted to the hospital for procedures, watch for the development of these symptoms in postoperative patients.

Untreated alcohol withdrawal can progress to delirium tremens (DT) 2 - 4 days after the patient's last drink, which can be fatal in up to 5% of cases. This condition is characterized by an altered sensorium and autonomic stability.

Rule out:

  • Infection

  • Hypoxia

  • Bleeding

  • Metabolic derangements

  • Preexisting seizure disorder


A benzodiazepine, like chlordiazepoxide (long-acting), is indicated for the treatment of moderate-to-severe alcohol withdrawal. They are not used to treat AUD itself, and have a high risk of abuse.

Consider whether the patient has liver disease. In these patients, choose a benzodiazepine without active metabolites, like lorazepam.

Lorazepam is an intermediate-duration benzodiazepine available in IV form, that is preferred in the inpatient setting, particularly in patients with comorbid liver disease.

Certain anticonvulsants can be used in certain situations, but none are first-line. Carbamazepine may be used for mild alcohol withdrawal. Phenobarbital has use as an adjunct to benzodiazepines in treatment-refractory alcohol withdrawal and withdrawal-related seizures.