Critical Cases - Alcohol Withdrawal Syndrome!


  • 54 year old male with history of alcohol use disorder presents complaining of restlessness and tremor
  • He drinks a case (24 beers) per day
  • His last drink was 12 hours prior
  • He feels "bus crawling" on his skin, tremor, and nausea

Physical Exam

T 97.7  BP 185/90 HR 124 Pox 94%

  • General: Restless, diaphoretic, +actively vomiting (non-bilious, non-bloody)
  • Heart: tachycardic
  • Pulm: Lungs clear
  • Abdomen: Soft, nontender
  • Neuro: alert and oriented, gross tremor of upper extremities
  • Psych: anxious


  • History and exam strongly suggestive of alcohol withdrawal syndrome
  • Sympathomimetic use also a possibility


  • Treatment with a symptom-triggered protocol is preferred
  • A widely used scoring system for severity of withdrawal symptoms is the CIWA-Ar score found here
  • A CIWA score >10 should be treated initially with IV/PO diazepam 20 mg
  • If CIWA still >10 after one hour, can double dose to IV/PO diazepam 40 mg, then to 60-80 mg after another hour if symptoms not improving


  • Discharge home on a benzo taper with close outpatient followup if CIWA<10
  • Consider admission for: poor ability to followup, problems with access to medications/filling prescriptions, refractory symptoms, or evidence of respiratory depression

Alternative therapy

  • Although benzodiazepenes are considered first line, there is mounting evidence for use of phenobarbital or gabapentin as first line agents