Alcohol withdrawal: Inpatient management

Management

Start aggressive Benodiazepine therapy at CIWA score of 8. Consider ICU admission with score >20

Benzodiazepines

• Diazepam (Valium) 5-10mg IV (depending on severity)
  • May repeat q5-10min for severe withdrawal (double dose until desired effect achieved)
• Lorazepam (Ativan) 1-4mg IV (depending on severity)
  • May repeat q15-20min for severe withdrawal (titrated to effect)
  • Rarely causes hepatitis, as opposed to diazepam which may cause a cholestatic hepatitis

Special Situations

• The propylene glycol diluent in lorazepam, phenobarbital and diazepam, may induce a hyperosmolar anion gap metabolic acidosis if given as a drip in high doses ≥ 48hrs. Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for Delirum tremens

Alpha-2 agonists (Dexmedetomidine)

• Decrease severity of sxs, but only supplemental to GABA-ergic first-lines
• Dexmedetomidine drip, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min

Barbituates (Phenobarbital)

• Used when refractory to benzodiazepines
• Phenobarbital 130-260 mg IV q 15-20 minutes

Ketamine

• May have some use in refractory cases
• Blocks the NMDA receptor which is excited an unregulated.

Nutritional supplementation

• Banana bag
  • Thiamine 100mg IV
  • Folate 1mg IV (cheaper PO)
  • MVI 1 tab IV (cheaper PO)
  • Magnesium sulfate 2mg IV
  • Normal saline as needed for hydration

See Also

• Beer Potomania Syndrome
• Alcohol (ETOH) Intoxication
• Alcoholic ketoacidosis
• Alcohol withdrawal
• Alcohol withdrawal: Inpatient management
• Alcohol withdrawal: Outpatient management
• Alcohol withdrawal seizures
• Altered mental status
• Delerium tremens
• EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal
• Sedative/Hypnotic
• Wernicke-Korsakoff Syndrome

External Links

• MDCalc - CIWA-AR Calculator