Pathophysiology and Timeline
Pathophysiology: chronic alcohol use → upregulation of NMDA (excitatory) receptors + downregulation of GABA-A (inhibitory) receptors to compensate for alcohol's CNS depression. Abrupt cessation → CNS hyperexcitability. Timeline: 6–24h: minor withdrawal — tremors, anxiety, diaphoresis, tachycardia, hypertension, insomnia, nausea. 12–24h: alcoholic hallucinosis — visual/auditory/tactile hallucinations WITH intact orientation (patient knows they are hallucinating — NOT delirium). 24–48h: seizures — generalized tonic-clonic; typically brief and self-limited; do NOT routinely treat with phenytoin (benzodiazepines are treatment). 48–72h (up to 5 days): delirium tremens — confusion/disorientation + autonomic instability (tachycardia, hypertension, diaphoresis, fever) + hallucinations (visual). 5% mortality with treatment, 15–35% untreated.
CIWA-Ar Protocol
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar): 10 items scored 0–7 each (maximum 67). Items: nausea/vomiting, tremor, diaphoresis, anxiety, agitation, paresthesias, visual disturbances, auditory disturbances, headache, orientation/clouding of sensorium. Score interpretation: ≤8 mild; 9–15 moderate; >15 severe. Symptom-triggered therapy (preferred over fixed-schedule): administer benzodiazepine when CIWA score >8–10. Prevents over-sedation and shortens treatment duration. Benzodiazepines (treatment of choice): long-acting (diazepam, chlordiazepoxide) — self-tapering, preferred for uncomplicated withdrawal in young patients with normal liver function. Short-acting (lorazepam, oxazepam) — preferred in liver disease, elderly, or pulmonary compromise (less hepatic metabolism, safer). IV lorazepam for seizures.
Delirium Tremens and Wernicke Encephalopathy
Delirium tremens: most severe form — disorientation (distinguishes from alcoholic hallucinosis), severe autonomic instability, hyperthermia, agitation. Treatment: ICU, high-dose IV benzodiazepines (diazepam 5–10mg IV q5–15 min until sedation), barbiturates or propofol for refractory DTs, IV fluids, monitor electrolytes (hypomagnesemia, hypokalemia, hypophosphatemia, hypoglycemia). Thiamine (Vitamin B1) BEFORE glucose: always give thiamine 100mg IV before any glucose — administering glucose before thiamine can precipitate Wernicke encephalopathy (Wernicke triad: confusion + ophthalmoplegia + ataxia). Wernicke progresses to Korsakoff syndrome (confabulation + anterograde amnesia + retrograde amnesia) if untreated — largely irreversible.