History

• 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

DDx

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

Treatment

• 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

Disposition

• 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