Alcohol Withdrawal Syndrome (AWS)

Scope - This entry is the withdrawal state itself. Chronic drinking and alcoholic liver disease are covered separately and carry their own drug-handling, coagulation, and MAC questions.

Ask when the last drink was - The timestamp is what lets you predict the window. Severity is graded by symptoms rather than by the clock, but without knowing when they stopped you cannot anticipate the postoperative day this patient gets into trouble.

Score it with CIWA-Ar - The Clinical Institute Withdrawal Assessment for Alcohol, revised is the tool that decides who needs pharmacologic treatment and how much. Order serial scoring on the patient you are worried about instead of relying on a subjective impression of agitation.

Know who withdraws badly - Prior delirium tremens, thrombocytopenia, and hypokalemia are the features that raise suspicion for severe withdrawal. In a trauma cohort with withdrawal symptoms, about half scored above 20 on CIWA-Ar and 24% progressed to DT. A withdrawal seizure carries roughly a 3% incidence of status epilepticus.

The postoperative patient nobody screened - This is the classic miss: postoperative day two or three, tachycardic, hypertensive, febrile, diaphoretic, agitated, and it gets charted as pain or early sepsis. Before accepting that, get the drinking history and rule out the same mimics the withdrawal workup covers - dehydration, infection, cardiac causes, electrolyte abnormalities, GI bleeding, and occult traumatic injury. Benzodiazepine and barbiturate withdrawal look identical, so pull the medication list too.

Benzodiazepines are the treatment - Long-acting benzodiazepines are the hallmark of managing severe symptoms, given as IV diazepam or IV lorazepam. Severe cases need escalating doses and ICU-level monitoring, often at doses higher than feel comfortable; that is the expected course. Oral chlordiazepoxide and oxazepam are the common regimens for preventing withdrawal.

When benzodiazepines are not enough - Withdrawal seizures usually respond to benzodiazepines but may need phenytoin or a barbiturate, and some patients require intubation and sedation with propofol, ketamine, or dexmedetomidine. Propofol is the described agent for refractory delirium tremens.

Thiamine goes with the dextrose - Wernicke-Korsakoff risk is why the standard cocktail pairs thiamine, folate, and a multivitamin with dextrose-containing fluid. Give it as a package rather than hanging glucose on its own.

Fix the volume and the electrolytes - Supportive care for mild to moderate withdrawal is IV rehydration plus correction of electrolyte abnormalities. These patients are commonly folate and thiamine deficient, and some benefit from magnesium supplementation. Send a metabolic panel and a magnesium level; do not induce a hypokalemic, hypomagnesemic, volume-down patient who is actively withdrawing.

Check a glucose - Poor nutrition leaves many chronic drinkers with a baseline ketoacidosis, and depleted hepatic glycogen means they can be euglycemic or frankly hypoglycemic despite the ketones. A point-of-care glucose costs nothing and changes what you hang.

Look for the co-ingestion when the picture does not fit - Prolonged altered sensorium or significant renal abnormality raises isopropyl alcohol, ethylene glycol, or methanol. Mouthwash and cough syrup carry alcohol along with salicylate or acetaminophen, so send those levels when the story is off.

Delaying an elective case is a legitimate answer - Untreated delirium tremens carries mortality around 15%, and treatment takes days rather than hours. A patient entering withdrawal in the holding area is worth postponing until they are scored, loaded, and stable.

Ethanol is a CNS depressant that inhibits excitatory glutamate signaling and enhances inhibitory GABA transmission. With prolonged use the brain resets around that suppression, so when drinking stops the inhibition is withdrawn and the CNS sits in excitatory overload, which is the autonomic storm that defines alcohol withdrawal syndrome (AWS). Mild signs appear within about six hours of the last drink: hypertension, insomnia, tremor, hyperreflexia, anxiety, GI upset, headache, palpitations. Withdrawal seizures, usually generalized, cluster at 12 to 24 hours, and roughly half of patients who seize go on to delirium tremens (DT). DT is the severe end, an altered sensorium with visual hallucinations, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis, and it can run seven days or longer. Reported mortality is 1% to 5% treated and around 15% untreated.