View source for Alcohol withdrawal seizures

==Background==
*Generalized tonic-clonic seizures occurring in the context of [[alcohol withdrawal]]
*'''Onset:''' 6-48 hours after last drink (peak at 24 hours)
*Multiple seizures occur in ~60% of patients
*~33% progress to [[delirium tremens]] if untreated
*May occur as isolated finding or as part of the broader [[alcohol withdrawal]] spectrum
*'''Key pearl:''' First-time seizure in a chronic alcoholic still requires full workup — do not assume alcohol withdrawal without ruling out other causes

==Clinical Features==
*Brief, generalized tonic-clonic seizures (usually <5 minutes)
*Typically self-limited
*'''Focal seizure features or prolonged seizure suggest an alternative or concurrent etiology''' (intracranial hemorrhage, CNS infection, structural lesion)
*Post-ictal period may be brief

==Differential Diagnosis==
{{Ethanol DDX}}
{{Seizure DDX}}

==Evaluation==
*'''Do not anchor on withdrawal''' — rule out other causes especially in first-time seizures:
**Glucose, BMP (electrolytes, magnesium), CBC
**CT head: obtain if first seizure, focal findings, prolonged altered mental status, head trauma, or anticoagulation
**Consider LP if fever or meningeal signs
*Assess CIWA score to guide withdrawal severity
{{CIWA score}}
*Ethanol level, [[urine toxicology screen]]
*Magnesium and phosphate levels (commonly depleted in alcoholics)

==Management==
*'''Benzodiazepines are first-line''' for both acute seizure treatment and withdrawal prophylaxis:
**[[Lorazepam]] 2-4 mg IV for active seizure
**[[Diazepam]] 10-20 mg IV for active seizure (faster onset, longer acting)
*'''Do NOT use phenytoin or fosphenytoin''' for alcohol withdrawal seizures (ineffective and potentially harmful)
*Replete electrolytes: magnesium (2g IV), thiamine (100-500 mg IV BEFORE glucose), folate
{{Inpatient management of ETOH withdrawal}}

==Disposition==
*Admit for observation and monitored benzodiazepine protocol
*ICU if: status epilepticus, refractory seizures, concern for delirium tremens, hemodynamic instability
*Consider outpatient management only if: isolated seizure, no other concerning features, reliable follow-up, safe discharge plan

==See Also==
*[[Alcohol withdrawal]]
*[[Delirium tremens]]
*[[Seizure]]
*[[Status epilepticus]]

==References==
<references/>

[[Category:Neurology]]
[[Category:Psychiatry]]
[[Category:Toxicology]]