01Approach to the Critical Patient/attcp95

Immediate priorities

›Stabilization priorities

›Airway protection triggers

›GCS < 8

›Refractory vomiting with aspiration risk

›Severe agitation preventing oxygenation or monitoring

›Breathing targets

›SpO2 94% to 98%

›If chronic hypercapnia risk, SpO2 88% to 92%

›Circulation targets

›MAP at least 65 mmHg

›SBP at least 90 mmHg

›Immediate reversible causes of delirium

›Hypoglycemia

›Hypoxia

›Hyperthermia

›Sepsis

›High risk withdrawal recognition

›Delirium tremens features

›Delirium

›Autonomic hyperactivity

›Severe agitation

›Hallucinations

›Onset typically 48 to 96 hours after last drink

›Withdrawal seizure risk window

›6 to 48 hours after last drink

›Wernicke encephalopathy risk

›Confusion

02History/hx70

Focused elements

›Withdrawal timeline

›Time of last alcohol

›Hours since last drink

›Prior peak severity timing

›Typical progression features

›Tremor onset time

›Hallucinations onset time

›Seizure onset time

›Alcohol exposure

›Daily quantity

›Standard drinks per day

›Pattern of binge use

›Duration of heavy use

›Months or years

›Recent reduction or cessation

›Abrupt stop

›Forced abstinence

›Prior severe withdrawal

›Prior delirium tremens

›Prior withdrawal seizures

›Prior ICU admission for withdrawal

›Co-substances

›Benzodiazepines

›Opioids

›Stimulants

›Cannabis

›Comorbid illness raising risk

03Physical Exam/exam53

Key findings and severity markers

›Vital signs and instability

›Autonomic hyperactivity

›Tachycardia

›Hypertension

›Fever

›Diaphoresis

›Respiratory compromise

›Bradypnea from sedatives

›Hypoxia

›Neurologic and mental status

›Withdrawal signs

›Tremor

›Hyperreflexia

›Mydriasis

›Delirium markers

›Inattention

›Disorientation

›Agitation

›Seizure evidence

›Tongue bite

›Postictal confusion

›Wernicke encephalopathy signs

›Nystagmus

›Ophthalmoplegia

›Gait ataxia

›Trauma and alternate cause screen

›Head and neck

04Differential Diagnosis/ddx28

Life threats and common mimics

›Delirium differential

›Alcohol withdrawal delirium (ICD-10 F10.231)

›Sepsis associated encephalopathy (ICD-10 R65.20)

›Hypoglycemia (ICD-10 E16.2)

›CNS infection (ICD-10 G00.9)

›Intracranial hemorrhage (ICD-10 I62.9)

›Toxic ingestion

›Ethylene glycol (ICD-10 T51.2)

›Methanol (ICD-10 T51.1)

›Seizure differential

›Withdrawal seizure (ICD-10 F10.239)

›Epilepsy (ICD-10 G40.909)

›Hyponatremia (ICD-10 E87.1)

›Hypomagnesemia (ICD-10 E83.42)

›Stimulant intoxication (ICD-10 F15.929)

›Agitation and psychosis differential

›Primary psychosis (ICD-10 F29)

›Manic episode (ICD-10 F30.9)

›Serotonin syndrome (ICD-10 T43.205A)

›Neuroleptic malignant syndrome (ICD-10 G21.0)

›Thyroid storm (ICD-10 E05.91)

Medical complications of alcohol use

›Complication differential

›Alcoholic ketoacidosis (ICD-10 E87.2)

›Pancreatitis (ICD-10 K85.90)

›Upper GI bleed (ICD-10 K92.2)

›Hepatic encephalopathy (ICD-10 K72.90)

05Laboratory Tests/lt72

Core labs and immediate corrections

›Baseline panel

›Electrolytes and renal function

›Sodium

›Potassium

›Chloride

›Bicarbonate

›Creatinine

›Glucose

›Point of care glucose mmol/L for altered mental status

›Recheck after dextrose therapy

›Magnesium

›Replacement threshold planning

›Arrhythmia and seizure risk modifier

›Phosphate

›Refeeding risk marker

›Respiratory muscle weakness risk

›Hematology and liver

›Complete blood count

›Leukocytosis for infection consideration

›Thrombocytopenia for liver disease and bleed risk

›Liver panel

›AST

›ALT

›ALP

›Bilirubin

›Albumin

›Coagulation

06Diagnostic Tests/dt50

Scoring Systems

›Validated tools

›CIWA-Ar

›Symptom triggered benzodiazepine suitability

›Not reliable in delirium or intubation

›PAWSS

›Predicts severe withdrawal risk

›Useful for prophylaxis planning

›MINDS

›ICU oriented monitoring alternative

›Useful when CIWA-Ar not feasible

›Application rules

›CIWA-Ar limitations

›Requires patient report and cooperation

›Overestimates in primary psychosis

›Severe withdrawal clinical override

›DT treated as severe regardless of score

MRI

›Neuroimaging indications

›Persistent focal neurologic deficit after stabilization

›Suspected Wernicke encephalopathy with atypical course

›Concern for encephalitis with normal CT

›Practical limitations

›Limited feasibility in severe agitation

›Airway and monitoring constraints

CT

›Head CT indications

›Head trauma history

07Disposition/dispo30

Level of care criteria

›Discharge suitability

›Mild symptoms controlled with oral regimen

›No history of DT or withdrawal seizures

›No significant comorbidity

›Reliable support

›Safe environment

›Inpatient ward indications

›Moderate symptoms requiring repeated dosing

›Unreliable outpatient follow up

›Significant electrolyte derangements

›Pregnancy

›Frailty or significant comorbidity

›ICU indications

›Delirium tremens

›Recurrent seizures

›Severe autonomic instability

›Need for phenobarbital loading with close monitoring

›Need for dexmedetomidine or propofol infusion

›Transfer criteria

›No ICU capability locally

›Refractory withdrawal despite escalating therapy

›Need for mechanical ventilation

Consults and pathways

›Consultation triggers

›Critical care for DT or refractory withdrawal

›Toxicology for phenobarbital strategy and mixed intoxication

›Psychiatry for primary psychosis or safety concerns

08Treatment/t104

Core supportive care

›Support bundle

›Thiamine

›Thiamine IV 500 mg every 8 hours for 2 to 3 days for suspected Wernicke encephalopathy

›Then thiamine IV or PO 250 mg daily for 3 to 5 days

›Then thiamine PO 100 mg daily

›Dextrose

›Dextrose IV for hypoglycemia after thiamine when feasible

›Fluids

›Isotonic crystalloid for hypovolemia

›Avoid excessive free water with hyponatremia risk

›Electrolytes

›Magnesium sulfate IV replacement when low or suspected

›Typical severe depletion strategy

›Magnesium sulfate IV 2 g to 4 g

›Repeat based on level and symptoms

›Potassium replacement

›Replace after magnesium strategy if both low

›Phosphate replacement

›Moderate to severe hypophosphatemia protocol per local standard

›Vitamins

›Folic acid PO 1 mg daily

›Multivitamin supplementation

Benzodiazepines

›First line therapy

›Diazepam

›Symptom triggered bolus

›Diazepam PO or IV 10 mg to 20 mg

›Repeat every 5 to 15 minutes for severe agitation until controlled

›Longer acting agent for smoother course

›Front loading approach

›Diazepam IV 10 mg every 5 to 10 minutes

›Typical total 40 mg to 100 mg

›Stop when calm but arousable

›Lorazepam

›Preferred in severe liver disease or older adults

›Lorazepam IV 2 mg to 4 mg

›Repeat every 10 to 20 minutes as needed

›Continuous dosing pathway

›Lorazepam IV 1 mg to 2 mg every 1 to 2 hours

›Escalate to infusion only in ICU setting

›Chlordiazepoxide

›Oral option for mild to moderate withdrawal

›Chlordiazepoxide PO 25 mg to 50 mg

›Repeat every 4 to 6 hours

›Safety considerations

›Respiratory depression risk

›Co-ingested opioids

›OSA

›COPD

›Paradoxical agitation consideration

›Escalate to phenobarbital strategy if suspected

Phenobarbital

›Indications and approach

›Benzodiazepine resistant withdrawal

›Persistent agitation despite high dose benzodiazepines

›Autonomic instability despite therapy

›Loading strategy

›Phenobarbital IV 10 mg/kg to 15 mg/kg total load

›Divide into 130 mg to 260 mg IV doses

›Repeat every 15 to 30 minutes until target achieved

›Maintenance strategy

›Phenobarbital PO 60 mg to 130 mg every 8 to 12 hours

›Taper based on clinical course

›Monitoring and contraindications

›Continuous monitoring for respiratory depression

›Avoid in severe respiratory failure without ICU support

›Additive sedation with benzodiazepines

Adjuncts and rescue therapies

›Alpha-2 agonist adjunct

›Dexmedetomidine

›ICU adjunct for autonomic hyperactivity

›Does not prevent seizures

›Use only with adequate GABAergic therapy onboard

›Anesthetic sedation

›Propofol

›Refractory DT requiring intubation

›Provides GABAergic effect and seizure protection

›Antipsychotics

›Haloperidol

›Severe hallucinations or agitation adjunct

›Does not treat withdrawal pathophysiology

›Seizure threshold lowering consideration

›QT prolongation monitoring

›Symptom adjuncts

›Antiemetic

›Ondansetron PO or IV 4 mg to 8 mg as needed

›Analgesia

›Avoid routine opioids

›Consider acetaminophen dose adjustment in liver disease

›Seizure management

›Single withdrawal seizure

›Benzodiazepine optimization

›No routine long term antiepileptic initiation for isolated withdrawal seizure

›Status epilepticus

›Standard status pathway

›Benzodiazepine first

›Escalation per ICU protocol

Alcohol use disorder treatment initiation

›In hospital linkage

›Brief intervention

›Referral to treatment

›Pharmacotherapy planning after stabilization

›Naltrexone consideration

›Avoid in acute hepatitis or opioid use

›Acamprosate consideration

›Renal dosing considerations

›Disulfiram consideration

›Only with strong supervision and motivation

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Maternal and fetal risks

›Withdrawal linked to fetal distress risk

›Low threshold for admission

›Medication considerations

›Benzodiazepines acceptable when benefits outweigh risks

›Avoid undertreatment of severe withdrawal

›Obstetric involvement

›Fetal monitoring when viable gestational age

›Delivery planning if unstable

Geriatric

›Older adult considerations

›Presentation differences

›Lower dose requirements

›Higher delirium risk from comorbidity

›Medication strategy

›Prefer lorazepam over diazepam with liver disease and frailty

›Slower titration

›Complication vigilance

›Falls

›Aspiration

›Arrhythmia

Pediatrics

›Pediatric considerations

›Epidemiology

›Withdrawal uncommon but possible with heavy sustained use

›Dosing framework

10Background/b42

Epidemiology

›Alcohol withdrawal overview

›Occurs after abrupt reduction or cessation in dependent individuals

›DT is the most severe withdrawal form

›DT historically associated with substantial mortality without treatment

›Risk factors for severe withdrawal

›Prior delirium tremens

›Prior withdrawal seizures

›Heavy daily intake

›Older age

›Significant medical comorbidity

›Electrolyte abnormalities

Pathophysiology

›Neuroadaptation model

›Chronic alcohol effect

›GABA-A enhancement

›NMDA inhibition

›Compensatory changes

›GABA downregulation

›NMDA upregulation

›Withdrawal state

›CNS hyperexcitability

›Autonomic hyperactivity

›Seizure mechanism

›Lowered seizure threshold from glutamatergic excess

›Delirium tremens mechanism

›Widespread neurotransmitter imbalance

›Sympathetic surge

11Patient Discharge Instructions/pdi26

copy discharge instructions

›Discharge plan

›No alcohol use while on sedating medications

›No driving or operating machinery for 24 hours after last sedating dose

›Hydration and nutrition

›Regular fluids

›Small frequent meals

›Vitamins

›Thiamine as prescribed

›Folic acid as prescribed

›Follow up

›Primary care within 2 to 7 days

›Addiction treatment referral within 1 week

›Return to ED now

›Confusion

›Hallucinations

›Seizure

›Chest pain

›Shortness of breath

›Persistent vomiting

›Black stools

›Fever

›Severe tremor or agitation not controlled

›Harm reduction

›Avoid abrupt stopping without medical plan if heavy daily use resumes

›Do not mix alcohol with benzodiazepines or opioids

›Crisis support access if feeling unsafe

12References/r15

Guidelines and high yield sources

›Source set

›American Society of Addiction Medicine clinical guideline for alcohol withdrawal management

›Severity stratification

›Benzodiazepine first line recommendations

›Level of care guidance

›NICE guideline on alcohol use disorders

›Acute withdrawal and delirium management pathways

›Thiamine prophylaxis recommendations

›VA and DoD clinical practice guidance for substance use disorders

›Withdrawal and AUD pharmacotherapy considerations

›Evidence and reviews

›Benzodiazepines efficacy for preventing seizures and DT supported by broad evidence base

›Phenobarbital protocols supported by observational studies and growing comparative literature

›Dexmedetomidine and propofol roles primarily ICU adjunct or rescue

›Internal project specification citation

Evidence & Review

Evidence & Review