Approach to the Critical Patient

Immediate stabilization

Time-critical threats in ethanol withdrawal

Monitoring and targets

Monitoring bundle for moderate-severe withdrawal

Escalation triggers

ICU transfer indications

Immediate consults

Consultation triggers

History

Onset and timeline

Last drink timing

Alcohol use pattern

Quantity and frequency

Prior withdrawal history

Prior complicated withdrawal

Current symptom profile

Withdrawal symptom progression

Concurrent substance use

Polysubstance use

Risk factor screen

High-risk features

Social history

Functional context

Physical Exam

Vital signs

Autonomic markers

Neurological exam

Mental status

Motor and reflex exam

Tremor assessment

Ocular exam

Eye findings

Skin and sweating

Diaphoresis

Abdominal exam

Hepatic and GI assessment

Differential Diagnosis

Life-threatening mimics

Must-not-miss diagnoses

Autonomic mimics

Conditions with autonomic hyperactivity

Sedative withdrawal mimics

Benzodiazepine withdrawal

Metabolic causes

Electrolyte and metabolic disorders

Laboratory Tests

Essential initial labs

Point-of-care glucose

Electrolytes and metabolic panel

Comprehensive metabolic panel

Liver function tests

Hepatic profile

Hematology

Complete blood count

Toxicology

Serum ethanol level

Additional targeted labs

Cardiac markers

Diagnostic Tests

Scoring Systems

CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol)

PAWSS (Prediction of Alcohol Withdrawal Severity Scale)

AUDIT-C (Alcohol Use Disorders Identification Test - Consumption)

MRI

MRI brain indications in ethanol withdrawal

CT

CT head indications

CT chest

Ultrasound

Bedside POCUS applications

Disposition

Discharge criteria

Outpatient (ED discharge) eligibility

Admission criteria

General ward admission indications

ICU admission criteria

High-acuity indications

Transfer criteria

Transfer indications

Treatment

Immediate interventions

Initial resuscitation bundle

Benzodiazepine therapy

First-line pharmacotherapy for AWS

Phenobarbital

Second-line or adjunct therapy

Gabapentin

Mild-to-moderate withdrawal alternative

Carbamazepine

Alternative for mild-moderate withdrawal

Seizure management

Active withdrawal seizure

Adjunct medications

Symptom-specific adjuncts

Nutritional supplementation

Vitamin and mineral replacement

Special Populations

Pregnancy

Ethanol withdrawal in pregnancy

Geriatric

Elderly-specific considerations (age > 65 years)

Pediatrics

Adolescent and pediatric considerations

Background

Epidemiology

Prevalence and burden

Pathophysiology

Mechanism of CNS hyperexcitability

Withdrawal stage timeline

Therapeutic Considerations

Benzodiazepine mechanism

Thiamine pharmacology

Phenobarbital rationale

Patient Discharge Instructions

copy discharge instructions

Discharge instructions for ethanol withdrawal

References

Guidelines and key sources

ASAM Clinical Practice Guideline on Alcohol Withdrawal Management (2020)

Schuckit MA. Recognition and Management of Withdrawal Delirium (Delirium Tremens). NEJM 2014

Diaz LA, Konig D, Weber S et al. Management of Alcohol Use Disorder. Lancet Gastroenterol Hepatol 2025

Wood E, Albarqouni L, Tkachuk S et al. Will This Hospitalized Patient Develop Severe Alcohol Withdrawal Syndrome? JAMA 2018

Gauer RL, Abellada A, Stewart M, Kozloski R. Managing Selected Chronic Conditions in Hospitalized Patients. Am Fam Physician 2024

Tiglao SM, Meisenheimer ES, Oh RC. Alcohol Withdrawal Syndrome: Outpatient Management. Am Fam Physician 2021

Haber PS. Identification and Treatment of Alcohol Use Disorder. NEJM 2025

Chand PK, Panda U, Mahadevan J, Murthy P. Management of Alcohol Withdrawal Syndrome in Patients with Alcoholic Liver Disease. J Clin Exp Hepatol 2022