Emergency Department Management of Alcohol Withdrawal Syndrome

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Emergency Department Management of Alcohol Withdrawal Syndrome

Left ArrowStart treatment Right Arrow headEmergency Department Management of Alcohol Withdrawal Syndrome

Considerations

Consider differential diagnoses, including non-accidental trauma, subdural hemorrhage, alcoholic ketoacidosis, sepsis, delirium, other acute intoxication or withdrawal, and hypo- or hyper-glycemia. 

Assess for Wernicke's encephalopathy, which is an underdiagnosed neurologic emergency; early treatment with 500 mg thiamine IV is critical.

Consider admission for patients with a history of complicated alcohol withdrawal syndrome (AWS). 

Do not use phenobarbital and consider expert consultation in patients who:

  • Are pregnant
  • Have uncertain or multiple toxidromes (e.g., concurrent opioid and/or benzodiazepine withdrawal, stimulant intoxication, etc.)

Phenobarbital doses are calculated by Ideal Body Weight (IDW), not actual weight. Max dose of 30mg/kg/day is recommended.

IV administration of diazepam and phenobarbital is recommended to better titrate and assess effect. Thiamine should also be given IV for rapid and improved absorption.

The RASS score is used in this protocol instead of CIWA because it is simple, quick, and performs just as well as CIWA in the setting of alcohol withdrawal.

Protocol

Document icon Emergency department management of alcohol withdrawal syndrome Emergency department management of alcohol withdrawal syndrome flowchart

Related Protocols

Additional Clinical Guidance

  • Alcohol use disorder (AUD) is treatable.
    • Pharmacotherapy is evidence-based.
    • Recovery often requires multiple treatment attempts.
  • Stigma prevents help-seeking and worsens health outcomes.
    • Care teams must challenge biases to provide compassionate, evidence-based care.
    • Use non-stigmatizing, person-first language and trauma-informed care to promote engagement
Document icon ScalaNW_Alcohol-Withdrawal-Guidance

AssessmentAccordion Icon

  • The Richmond Agitation-Sedation Scale (RASS) is used to assess level of agitation, alertness, and sedation. The scale ranges from +4 (very agitated) to -5 (very sedated), with 0 representing an alert and calm state. Therapeutic goal is RASS 0 to –1.
  •  Advantages of RASS over CIWA-Ar for assessing alcohol withdrawal:
    • RASS is a rapid, single-item scale that does not require patients to answer questions.
    • CIWA-Ar can only be used in awake and alert patients and takes longer to assess.
  • CIWA-Ar may be used in addition or as an alternative

LabsAccordion Icon

  • Phenobarbital has predictable, linear pharmacokinetics; thus, serum levels generally do not need to be checked when remaining within the recommended dose of no more than 20mg/kg/day. Seek expert consultation if you consider exceeding this dose. Toxicity occurs with plasma levels >40 mcg/mL.

PharmacotherapyAccordion Icon

  • Phenobarbital is increasingly recommended over benzodiazepines to treat AWS; it is
    preferred because:
    • Studies comparing phenobarbital and benzodiazepine monotherapy have shown fewer ICU admissions from the ED and shorter hospital stays with fewer adverse events (physical restraints, intubation) after admission in those given phenobarbital over benzodiazepines.
    • Patients who receive phenobarbital are significantly less likely to return to the ED within 72 hours and have not been shown to experience more adverse events.
    • Phenobarbital affects both inhibitory (GABA) and excitatory (glutamate) neurotransmitters. Benzodiazepines potentiate the GABA receptor, which helps calm the patient, but have no effect on excitatory neurotransmitters, which can cause paradoxical agitation.
    • Phenobarbital has a rapid onset (5-20 min) and loading doses have a predictable, linear relationship to serum levels, and its maximum sedating effect occurs within 15 minutes of IV administration. It also has a long half-life (approximately 100 hours) with active metabolites, self-titrating over 3-4 days. This means that clinicians will see the deepest sedation while the patient is in the emergency department, but the protection from withdrawal symptoms will last for days after discharge.
    • Benzodiazepines may cause delirium and be misinterpreted as ongoing
      alcohol withdrawal.
  • Diazepam (Valium) is preferred over chlordiazepoxide (Librium) in acute care
    settings because:
    •  Diazepam can be given orally or IV with peak sedation within 30-45 minutes.
    • Use of chlordiazepoxide results in unpredictable levels of sedation due to delayed peak effect.
    • Diazepam has a longer half-life (30-56 hour) with active metabolites, so therapeutic effect is extended.
    • Patients who receive chlordiazepoxide often need a prescription to dose after discharge due to its shorter half-life (24-48 hours) and lack of active metabolites. After discharge, patients are at risk of oversedation if they combine chlordiazepoxide with alcohol.
  • Multiple or uncertain toxidrome(s):
    • Benzodiazepines are the best first-line therapy when the diagnosis is unclear or multiple toxidromes (e.g., concurrent opioid and/or benzodiazepine withdrawal, stimulant intoxication, etc.) are present.

PathophysiologyAccordion Icon

  • Alcohol withdrawal syndrome (AWS) typically occurs within 1-3 days following abrupt cessation or considerable decrease in heavy, chronic alcohol use. AWS ranges from mild to severe and can be life threatening.
  • AWS symptoms may include:
    • Autonomic: tachycardia, tachypnea, dilated pupils, elevated blood pressure, elevated body temperature, diaphoresis, nausea/vomiting, diarrhea.
    • Motor: tremor, seizures, ataxia, gait disturbances, hyperreflexia, dysarthria.
    • Psychiatric: irritability, anxiety, agitation, insomnia, delirium, disorientation, illusions, delusions, hallucinations, affect instability, disinhibition.
  •  Vitamin deficiency:
    • Patients are at high risk for thiamine (vitamin B1) and folate deficiency and should receive supplementation.
    • Thiamine supplementation prevents and treats Wernicke encephalopathy, which is life threatening.
  • Electrolyte imbalance:
    • Hyponatremia is common, especially amongst those who drink beer. This can be repleted with isotonic fluids.
    • Hypokalemia is common and should be corrected.
    • Patients are at risk for hypokalemia, hypophosphatemia and refeeding syndrome, and metabolic acidosis/alcohol-related ketoacidosis.
  • Severe/complicated AWS:
    • Severe AWS refers to seizures, autonomic dysfunction, delirium, and Wernicke encephalopathy.
    • Risk factors for severe withdrawal include history of severe AWS, medical comorbidities, and co-dependence on benzodiazepines.
Table for alcohol withdrawal syndrome

 Table adapted from Gottlieb et al. (2024) and Canver et al. (2024).

Special populationsAccordion Icon

  • Phenobarbital is contraindicated in pregnancy.

Patient safetyAccordion Icon

  • Monitor and maintain adequate fluid intake and electrolyte balance. Ensure thiamine and folate supplementation for all AWS patients.
  • If a patient is at risk for or experiencing severe AWS, administer indicated medications immediately to prevent complications.
  • Patients with symptoms of Wernicke’s encephalopathy must be urgently treated with IV thiamine.

Discharge planningAccordion Icon

  • Arrange transfer to withdrawal management facility for ongoing management, if
    indicated/preferred by patient.
  • Help the patient schedule a follow up appointment with primary care.
    • Ask the patient if they have an established provider and where they want to receive ongoing care.
    • Assist the patient with scheduling appointments and addressing barriers, like transportation. Refer to social work, if available.
    • Outpatient and inpatient/residential treatment programs can be found on the Department of Health’s Behavioral Health Agency Greenbook.
  • Discharge medications for AWS:
    • Most patients who receive diazepam or phenobarbital will not require a prescription for medications to treat ongoing AWS symptoms after discharge.
    • If the patient feels they need medications after discharge, consider gabapentin (first-line) or chlordiazepoxide (second-line):
      • Gabapentin 600mg TID
        • Gabapentin is preferred over a benzodiazepine due to less sedation risk.
        • Patient should have normal GFR and be under 65 years old.
        • Patient may continue this medication long term for management of AUD. See Medications for Alcohol Use Disorder.
        • If patient chooses not to continue gabapentin long term, advise against abrupt discontinuation due to seizure risk. Consider the following taper:
          • Gabapentin 300 mg tabs
          • Day 1: 1 tab every 6 hours
          • Day 2: 1 tab every 8 hours
          • Day 3: 1 tab every 12 hours
          • Day 4: 1 tab
          • May have one additional tab every 12 hours as needed x 5
          • Dispense #15
      • Chlordiazepoxide
        • Note delayed peak sedation and risk of oversedation if combined with alcohol. Discuss the risks and explain that the medication must not be combined with alcohol or other sedating substances.
        • Chlordiazepoxide is preferred over diazepam when unobserved because it is less sedating.
        • Prescribe:
          • Day 1: 50mg every 6 hours
          • Day 2: 25mg every 6 hours
          • Day 3: 25mg every 12 hours
          • Day 4: 25mg at night
          • Dispense #15, no refills
          • Do not use if consuming alcohol or taking other sedatives
  • Offer medications to treat alcohol use disorder. See Medications for Alcohol Use Disorder.
  • Provide naloxone for patients that use any street drugs and discuss safer use
    strategies, including not using alone

Patient educationAccordion Icon

Educate patients on:

  • Strategies to reduce the harms of alcohol (see Discharge Instructions).
  • Treatment options for alcohol use disorder (see Related Protocols).
  • The risks of combining alcohol with sedating substances.

Discharge Instructions

Treatment services

  • Medications for alcohol use disorder can help you reduce or stop drinking and feel better. Talk to your health care provider about options.
  • Contact the Washington Recovery Help Line at 866-789-1511 to learn about substance use treatment options.
  • Peer support, like AA or Smart Recovery, may be helpful. Ask your care team about available local and online resources.

Reduce the harms of drinking
If you continue drinking, follow these tips to reduce some of the harms alcohol can cause:

  • Don’t drink and drive. Have a safe transportation plan before you start drinking.
  • Eat and drink water before you drink alcohol.
  • Drink tea, water or other non-alcoholic beverages between drinks.
  • Space out the time between drinks.
  • Buy/order smaller servings.
  • Drink beer or other lower alcohol content drinks instead of liquor.
  • Drink slowly and take sips.
  • Avoid drinking rounds, especially with friends who drink heavily.
  • Avoid topping up your drink before it is empty.
  • Limit the amount of alcohol you keep in your home.
  • Schedule drinking and non-drinking days.
  • Avoid mixing alcohol with other drugs or medications that make you sleepy. The combination could make you so sleepy that you stop breathing. If you do use drugs with alcohol, try not to use alone, so that someone can call 911 if you stop breathing.

CAUTION 

  • During your visit, you may have received medications that make you sleepy. Avoid alcohol and other medications or drugs that can make this worse. The combination could make you so sleepy that you stop breathing. Do not drive until these medications wear off.
  • Know the signs and symptoms of alcohol poisoning: vomiting, loss of consciousness, decreased breathing, confusion, seizures, clammy skin. This is a medical emergency.
  • If you are dependent on alcohol, do not stop drinking suddenly. Stopping suddenly can cause withdrawal that may be dangerous. Work with a medical provider to get medications to help you withdrawal from alcohol safely.

References

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