›Cardiac and pulse oximetry monitoring for moderate to severe cases
›IV access
›Two large bore IVs if severe agitation or hemodynamic instability
›One IV if mild and stable
›Point of care glucose early
›Treat hypoglycemia promptly
›Recheck after correction
›Airway risk planning with escalating sedative needs
›Preparedness for assisted ventilation
›Early critical care involvement if worsening mental status
Symptom control and pharmacotherapy
›Benzodiazepine based strategy
›Symptom triggered regimen when CIWA Ar usable
›Diazepam 10 mg
›Repeat based on symptoms with frequent reassessment
›Fixed dosing or front loading when CIWA Ar not usable
›Lorazepam 2 mg at regular intervals
›Escalate based on agitation and vitals
›Phenobarbital strategy when indicated
›Consider when benzodiazepine refractory
›Consider when history of severe withdrawal with high recurrence risk
Supportive care and complication prevention
›Nutrition and vitamins
›Thiamine IV 200 mg before glucose when possible
›Folic acid 1 mg daily
›Magnesium repletion when low or borderline
›Fluids and electrolytes
›Balanced crystalloids for dehydration
›Potassium repletion guided by ECG and labs
›Phosphate repletion when low
Monitoring and reassessment loop
›Reassessment loop
›Recheck vitals every 15 to 30 minutes during escalation
›Repeat mental status assessment after each sedative dose cluster
›Repeat CIWA Ar or RASS at defined intervals
›Escalate to higher level of care if worsening despite therapy
Consultation and pathway planning
›Consultation and disposition planning
›Addiction medicine or withdrawal management services when available
›Internal medicine for comorbidity driven admission
›ICU for refractory severe withdrawal or airway risk
17Disposition/dispo19
ICU criteria
›ICU level care criteria
›Delirium tremens
›Recurrent or prolonged seizure
›Need for continuous sedative infusion
›Persistent hypoxia or hypercapnia
Inpatient admission criteria
›Inpatient admission criteria
›Moderate withdrawal with unreliable outpatient supports
›Significant comorbid illness
›Electrolyte derangements requiring serial repletion
›GI bleed or pancreatitis concern
Observation pathway criteria
›Observation criteria
›Mild to moderate symptoms responsive to initial therapy
›Stable vitals after treatment period
›Ability to reassess frequently
Discharge criteria
›Discharge criteria
›Mild symptoms with sustained improvement
›Normalizing vitals without escalating medication needs
›Reliable supervision and follow up within 24 to 72 hours
›No red flags for alternate diagnosis
18Discharge Instructions/di20
Copy discharge instructions
›Alcohol withdrawal symptoms improving today
›Symptoms can worsen over the next 24 to 72 hours after last drink
›Do not drink alcohol to treat symptoms
›Medications
›Take prescribed medications exactly as directed
›Avoid driving or operating machinery if sedating medications were given
›Avoid mixing sedatives with opioids or other substances
›Hydration and nutrition
›Drink fluids regularly
›Eat small frequent meals if nauseated
›Follow up
›Follow up with primary care or withdrawal management clinic within 1 to 3 days
›Addiction support resources as provided by the ED
›Return to the ED now for
›Seizure
›Confusion or hallucinations
›Chest pain
›Shortness of breath
›Persistent vomiting or inability to keep fluids down
›Fever
19References/r5
Guidelines and key sources
›Core evidence and guidelines
›American Society of Addiction Medicine alcohol withdrawal management guideline 2020
›NICE alcohol use disorders diagnosis assessment and management guideline CG115 2011 updated
›VA DoD clinical practice guideline for substance use disorders 2021
›Society for Academic Emergency Medicine alcohol withdrawal overview and education resources
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.