Critical Cases - Alcohol Withdrawal!


  • A 53-year-old male with a history of chronic daily alcohol use presents to the ED via EMS after a witnessed seizure at home
  • The medics say he drinks every day, but his last drink was 3 days ago because he was not able to go to the store (history obtained from the sister who witnessed the seizure)


Physical Examination

T 98.3 F BP 177/106 HR of 191 RR of 22 Sat of 93% 

  • Patient appears anxious, uncomfortable, and is actively vomiting blood tinged sputum
  • He appears confused and is not answering questions appropriately
  • He is tachycardic and his lungs are clear to auscultation bilaterally
  • Abd: soft NTND



  • Alcohol withdrawal/ Delirium Tremens
  • Thyrotoxicosis
  • Sepsis
  • Pulmonary embolism
  • Heart failure


Workup and Management

  • The nurse informs you that the patient is seizing
  • This patient is exhibiting evidence of delirium tremens (psychomotor agitation and autonomic instability) and alcohol withdrawal seizure
  • The patient is no longer tolerating his secretions, he is confused, gurgling, and requires a definitive airway
  • After intubation, you bolus the patient with propofol and start him a propofol infusion
  • The patient is admitted to the ICU for further management


Teaching Points

  • ETOH withdrawal begins 6-8 hours after last intake and peaks in 72 hours 
  • Symptom based treatment via the CIWA score can help stratify patients, scores >15 indicate severe withdrawal
  • Start with IV diazepam at 10mg or lorazepam at 4mg and repeat them in doubling doses
  • Consider adding phenobarbital for refractory cases (i.e. after 200 mg of diazepam)
  • Consider propofol as the induction agent and sedative post-intubation as propofol potentiates GABA receptor activity and inhibits NMDA receptors Summary 
  • Delerium tremens can result in death from hyperthermia, arrhythmia and seizures




Long D, Long B, Koyfman A. The emergency medicine management of severe alcohol withdrawal. The American Journal of Emergency Medicine. 2017;35(7):1005-1011. doi:10.1016/j.ajem.2017.02.002

Schuckit MA, Author Affiliations From the Department of Psychiatry. Recognition and Management of Withdrawal Delirium (Delirium Tremens): NEJM. New England Journal of Medicine. Published February 5, 2015. Accessed December 9, 2020.