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