ALCOHOL WITHDRAWAL
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Welcome to today’s episode of AudioBoards — the first episode of our Intern Series, your crash course through the most common hospital conditions.
Alcohol withdrawal occurs when a chronic heavy drinker suddenly stops or significantly reduces alcohol intake, and symptoms depend on time since the last drink.
Within 6 to 36 hours, patients develop tremors, anxiety, sweating, GI upset, and tongue fasciculations.
From 12 to 48 hours, risk increases for withdrawal seizures and alcoholic hallucinosis — visual or tactile hallucinations while oriented.
From 48 to 96 hours is the most dangerous phase — Delirium Tremens — with confusion, autonomic instability, tachycardia, hypertension, hyperthermia, and up to 5% mortality.
Why does this happen? Think of the brain like a car with two pedals.
The brake is GABA — calming.
The gas is glutamate — stimulating. Alcohol acts like extra GABA, slamming the brake. With chronic drinking, the brain adapts by removing GABA receptors and increasing glutamate receptors — creating tolerance. When alcohol stops, the brake is weak and the gas pedal is floored: low GABA, high glutamate. The nervous system enters overdrive, causing tremors, anxiety, sweating, tachycardia, hypertension, hallucinations, seizures, and delirium tremens.
Severity is measured using the CIWA scale, which guides symptom-triggered treatment rather than fixed dosing.
CIWA <10: outpatient care, often gabapentin
CIWA 10–15: outpatient or ED with long-acting benzodiazepines like diazepam or chlordiazepoxide
CIWA >15–20: inpatient symptom-triggered benzodiazepines
CIWA >20: severe withdrawal requiring intensive monitoring
Benzodiazepines are preferred for self-tapering effects. In liver disease, use LOT drugs — lorazepam, oxazepam, temazepam. If inadequate, phenobarbital may be added with ICU-level monitoring.
Hospitalized patients receive thiamine, fluids, and nutrition to prevent Wernicke’s encephalopathy.
Symptom-triggered dosing is preferred, with front-loading for severe withdrawal (CIWA ≥19).
Dosing in chlordiazepoxide equivalents:
Mild: 25–50 mg PO
Moderate: 50–100 mg PO
Severe: 75–100 mg PO
Symptom-triggered: 25–100 mg PO every 4–6 hours when CIWA ≥10, with PRN doses. Fixed taper:
Day 1 q4–6h
Day 2 q6–8h
Day 3 q8–12h
Day 4 bedtime
Optional Day 5 bedtime
Front-loading: 50–100 mg PO every 1–2 hours until CIWA <10 or for three doses
Phenobarbital: 10 mg/kg IV over 30 minutes or 60–260 mg PO/IM
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