Browse categories and answer follow-up questions to refine your symptom profile.
History
Presenting syndrome and timeline
Alcohol withdrawal syndrome context
Time since last alcohol intake
Pattern of symptom onset and progression after cessation or reduction
Prior withdrawal history
Prior withdrawal seizures
Prior delirium tremens
Baseline alcohol use pattern
Typical daily amount and duration of heavy use
Recent escalation or binge pattern
Recent cessation drivers
Illness
Unable to obtain alcohol
Key symptoms of withdrawal
Withdrawal symptom cluster
Tremor
Diaphoresis
Anxiety
Agitation
Nausea and vomiting
Insomnia
Perceptual disturbance
Visual hallucinations
Tactile hallucinations
Co ingestants and concurrent illness
Concurrent exposures and triggers
Benzodiazepines use or withdrawal
Opioids
Stimulants
GHB or other sedative hypnotics
Recent infection symptoms
Fever
Cough
Functional impact and safety
Impact and supports
Ability to maintain hydration and nutrition
Housing stability and supervision
Access to follow up and detox resources
Alarm Features
Immediate life threats
High risk withdrawal states
Withdrawal seizure
Delirium tremens
Severe autonomic hyperactivity
Persistent tachycardia despite initial therapy
Severe hypertension with end organ symptoms
Vital sign danger thresholds
High risk physiology
Temperature 38.0 C or higher
Heart rate 120 or higher
Systolic blood pressure 180 or higher
Respiratory rate 24 or higher
High risk exam findings
High risk findings
Altered mental status
Severe agitation or inability to be redirected
Focal neurologic deficit
Nuchal rigidity
Escalation triggers
Escalate level of care if
Refractory symptoms after adequate benzodiazepine dosing
Recurrent seizure activity
Hypoxia or respiratory depression after sedatives
Suspected alternative cause of delirium
Medications
Medication reconciliation and risks
Current medication exposures
Prescribed sedatives
Antiepileptics
Antipsychotics
Beta blockers
Clonidine
Withdrawal treatment medications
Benzodiazepines
Diazepam PO or IV 10 mg
Repeat every 10 to 15 minutes for severe symptoms
Longer acting option for symptom triggered therapy
Lorazepam PO or IV 2 mg
Preferred with advanced liver disease
Repeat every 15 to 20 minutes for severe symptoms
Chlordiazepoxide PO 50 mg
Avoid with significant liver disease
Longer acting outpatient option when appropriate
Phenobarbital
IV 130 mg
Repeat every 15 to 30 minutes to clinical effect
Avoid with severe respiratory compromise
Vitamin and electrolyte support
Thiamine
IV 200 mg
Give before glucose when possible
Folic acid
PO 1 mg daily
Continue during admission or detox course
Contraindications and interaction traps
Medication cautions
Avoid combining high dose sedatives with other respiratory depressants
Avoid flumazenil in suspected benzodiazepine dependence
QT prolonging agents caution with hypokalemia or hypomagnesemia
Diet
Intake and hydration
Recent intake status
Poor oral intake
Persistent vomiting
Signs of dehydration
Reduced urine output
Orthostasis
Caffeine and stimulant exposure
Sympathomimetic contributors
Energy drinks
High caffeine intake
Alcohol related nutrition risk
Malnutrition risk
Weight loss
Limited diet diversity
Review of Systems
Neurologic and psychiatric
Neuro and mental status symptoms
Headache
Confusion
Hallucinations
Seizure
Cardiopulmonary
Cardiopulmonary symptoms
Chest pain
Palpitations
Shortness of breath
GI and metabolic
GI and metabolic symptoms
Abdominal pain
Hematemesis or melena
Polyuria or polydipsia
Hypoglycemia symptoms
Collateral History and Family History
Collateral sources
Collateral reliability
Family or friends report
EMS report
Shelter or facility report
Family history risks
Relevant family history
Seizure disorders
Early cardiovascular disease
Social supports and supervision
Support and safety
Reliable observer available for 24 to 48 hours
Ability to return if worsening
Risk Factors
Withdrawal severity predictors
Severe withdrawal risk factors
History of delirium tremens
History of withdrawal seizure
Heavy daily use with long duration
Older age
Medical comorbidity risks
Comorbidity risks
Chronic liver disease
Heart failure
COPD or sleep apnea
Pregnancy
Infection and other triggers
Concurrent illness risks
Pneumonia
UTI
Pancreatitis
GI bleeding
Differential Diagnosis
Life threatening
Life threatening causes of agitation or delirium
Delirium tremens (F10.231)
Delirium plus autonomic instability after cessation
Hallucinations with severe tremor and diaphoresis
Sepsis (A41.9)
Fever or hypothermia with tachycardia
Hypotension or lactate elevation
Hypoglycemia (E16.2)
Diaphoresis and altered mental status
Rapid improvement with glucose
Intracranial hemorrhage (I61.9)
Head trauma
Focal deficit
Common
Common related diagnoses
Alcohol intoxication (F10.129)
Sedation and ataxia
Elevated ethanol level may coexist with withdrawal
Alcoholic ketoacidosis (E87.29)
Anion gap metabolic acidosis
Normal or low glucose
Anxiety disorder (F41.9)
Normal vitals or mild tachycardia
No clear withdrawal timeline
Less common and mimics
Less common and mimics
Benzodiazepine withdrawal (F13.239)
Similar autonomic hyperactivity
Recent benzo reduction
Thyrotoxicosis (E05.90)
Persistent tachycardia and heat intolerance
Goiter or tremor out of proportion
Serotonin syndrome (T43.205A)
Hyperreflexia or clonus
Recent serotonergic medication changes
Past Medical History
Substance use and prior care
Substance and withdrawal history
Prior detox admissions
Prior ICU admission for withdrawal
Other substance use disorder diagnoses
Neurologic history
Neurologic baseline
Epilepsy
Prior stroke or TIA
Hepatic and GI history
Liver and GI disease
Cirrhosis complications
Ascites
Variceal bleeding
Pancreatitis
Baseline function
Functional baseline
ADLs independence
Baseline cognition
Physical Exam
General and vitals interpretation
General and severity cues
Tremor at rest
Diaphoresis
Psychomotor agitation
Evidence of trauma
Vital sign patterns
Persistent tachycardia
Hypertension
Fever
Neurologic and mental status
Neurologic exam
Orientation and attention
Hallucinations or perceptual disturbance
Focal deficit screening
Gait if safe
Cardiopulmonary
Heart and lungs
Arrhythmia signs
Pulmonary edema signs
Wheeze or hypoventilation after sedatives
Abdomen and skin
Abdomen and skin
Abdominal tenderness
Jaundice
Spider angiomas
Track marks
Lab Studies
Core labs and thresholds
Essential labs for withdrawal and complications
Glucose
Treat if under 4.0 mmol/L
Recheck after treatment
Electrolytes
Potassium
Magnesium
Phosphate
Renal function
Creatinine
BUN
Hepatic and hematologic evaluation
Liver and hematology
AST and ALT
Bilirubin
INR
CBC
Acid base and tox evaluation
Metabolic and toxicology
VBG or ABG if respiratory concern or severe acidosis
Serum ketones if anion gap acidosis suspected
Ethanol level if unclear history or co intoxication
Pregnancy test if relevant
Pitfalls and limitations
Interpretation pitfalls
Normal ethanol level does not exclude withdrawal
Withdrawal can coexist with infection or GI bleed
Imaging
Scoring Systems
Withdrawal risk and severity tools
CIWA Ar
Use for mild to moderate withdrawal in cooperative patients
Not reliable with delirium or inability to answer
PAWSS
Use to predict severe withdrawal risk in hospitalized patients
High risk result supports early prophylaxis and monitored setting
MRI
MRI indications in atypical presentations
Persistent focal neurologic deficits
Concern for encephalitis or structural lesion after initial workup
CT
CT indications
Head CT for seizure with trauma
Head CT for focal deficit or unexplained altered mental status
Ultrasound
Ultrasound uses
RUQ ultrasound if biliary disease suspected
Cardiac POCUS if shock or pulmonary edema suspected
Special Tests
Bedside structured assessments
Bedside assessments
CIWA Ar symptom severity tracking when appropriate
RASS for agitation and sedation target in severe cases
COWS if concurrent opioid withdrawal suspected
Withdrawal seizure evaluation
Seizure focused evaluation
Recurrent seizure suggests alternative or mixed etiology
Persistent altered mental status suggests CNS infection or hemorrhage
ECG
Indications and high risk patterns
ECG triggers
Chest pain
Palpitations
Syncope
Significant electrolyte abnormalities
High risk findings
QTc prolongation
Atrial fibrillation with rapid ventricular response
Ventricular ectopy with hypokalemia or hypomagnesemia
Serial monitoring logic
Repeat ECG when
Marked electrolyte shifts after repletion
New chest pain or dyspnea
After QT prolonging medications
Assessment
Working diagnosis and severity
Alcohol withdrawal syndrome (F10.239)
Mild
Tremor and anxiety with stable vitals
No hallucinations
Moderate
Prominent autonomic symptoms
Nausea and vomiting affecting intake
Severe or complicated
Seizure
Delirium
Refractory autonomic instability
Complications to rule out
High impact complications
Wernicke encephalopathy (E51.2)
Confusion
Ataxia
Ophthalmoplegia or nystagmus
Alcoholic ketoacidosis (E87.29)
Anion gap acidosis
Recent binge and poor intake
Infection
Fever or leukocytosis
Localizing symptoms
Plan
First 5 minutes and stabilization
Immediate workflow
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
Disposition
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
Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.