In this in-depth episode of Hospital Medicine Unplugged, we tackle alcohol withdrawal syndrome (AWS)—why it’s high-stakes on the wards, how to risk-stratify fast, and exactly what to do from triage through discharge.
We open with the “why”: AWS is common, dangerous, and time-sensitive. We review the pathophysiology (rebound CNS hyperexcitability after abrupt cessation) and the clinical spectrum—from mild tremor and autonomic surge to seizures and delirium tremens—framing why early recognition changes outcomes.
Diagnosis and risk stratification come next. We show how to get the story that matters (prior DTs/seizures, daily quantity, last drink, polysubstance use, comorbids, electrolytes). We explain using CIWA-Ar the right way—as a monitoring tool, not a diagnostic test—and when it breaks down (ICU, delirium, non-communicative patients). We introduce objective alternatives (e.g., MINDS/mMINDS, vital-sign–driven checks) and map patients to the right setting: ambulatory for low-risk, floor/step-down for moderate, ICU for severe or refractory cases.
Then the treatment playbook:
• Benzodiazepines are first-line. Long-acting (diazepam, chlordiazepoxide) for most; lorazepam/oxazepam when liver disease or frailty raise the stakes.
• Symptom-triggered dosing wherever frequent reassessment is feasible; fixed-schedule or front-loading when monitoring is limited or the patient can’t participate.
• Escalation for severe AWS: IV lorazepam or diazepam; phenobarbital as monotherapy or adjunct in experienced hands; dexmedetomidine/propofol as ICU adjuncts (not seizure prophylaxis).
• Mild/outpatient cases: gabapentin or carbamazepine as alternatives when benzos are contraindicated—paired with daily check-ins.
Supportive care is non-negotiable: high-dose parenteral thiamine early (and don’t delay glucose if hypoglycemic—give both), multivitamins/folate, aggressive electrolyte repletion (Mg, K, PO₄), fluids and nutrition, quiet/light-stable environment, fall/aspiration precautions. We highlight red flags for delirium tremens (48–72 hours, agitated delirium, hallucinations, autonomic instability), seizure management (benzodiazepines first; antiepileptics only for non-AWS status), and clear triggers for ICU transfer.
Special populations get a focused walkthrough: advanced hepatic dysfunction (prefer lorazepam/oxazepam; avoid long-acting benzos and phenobarbital if decompensated), older adults (lower doses, delirium prevention), and pregnancy (benzos remain first-line for severe AWS; use the lowest effective dose).
We close with transition and long-term care: concrete discharge criteria (symptoms controlled, stable vitals, no recent seizures, eating/drinking, safe plan), addiction medicine consults, and starting relapse-prevention meds before discharge (naltrexone when liver allows; acamprosate for liver disease; disulfiram in highly selected/supervised patients). We build a follow-up bundle—early appointments, counseling/peer support, and return-precautions—that keeps patients safe after the protocol ends.
No fluff—just a ward-ready, guideline-driven path to safer alcohol withdrawal management.
