CCS Integrated Cases

CCS case: alcohol withdrawal in the inpatient unit

Clinical Overview and When to Suspect Alcohol Withdrawal

— ~50% of patients with alcohol use disorder (AUD) develop withdrawal when intake stops

— ~3–5% progress to delirium tremens (DT), with untreated mortality up to 15%

— Common precipitant in admitted patients: trauma, pancreatitis, GI bleed, pneumonia, postoperative NPO status

— Any admitted patient with documented heavy alcohol use, elevated MCV, AST:ALT >2:1, or unexplained tremor/tachycardia 6–48 h after admission

— "Found down" patients, fall with rib fractures, cirrhosis admission, post-op day 1–3 tachycardia/HTN with no infection

— Psychiatric admissions, homeless patients, and ED boarders are high-risk groups often missed

— 6–12 h: minor withdrawal — tremor, anxiety, insomnia, mild autonomic activation

— 12–24 h: alcoholic hallucinosis (visual/tactile, sensorium intact)

— 24–48 h: withdrawal seizures (generalized tonic-clonic, usually single or brief cluster)

— 48–96 h: delirium tremens — confusion, agitation, severe autonomic instability, fever

— Prior DT or withdrawal seizure (strongest predictor)

— Sustained heavy intake, older age, concurrent medical illness, electrolyte derangement (low K, Mg, phos), thiamine deficiency

— Initial CIWA-Ar ≥15 or admission BAC >200 mg/dL while appearing sober

CCS pearl: On any patient with AUD, place admission orders for CIWA-Ar q1h initially, thiamine 100 mg IV before any glucose, folate, multivitamin, and a benzodiazepine PRN protocol before you ever leave the order screen — withdrawal is a predictable, preventable inpatient emergency.

Definition: Alcohol withdrawal syndrome (AWS) is a hyperadrenergic state from abrupt cessation/reduction of chronic ethanol use, driven by unopposed glutamate (NMDA) excitation and decreased GABA tone.

Epidemiology on the wards:

When to suspect on a CCS case:

Timeline to memorize (anchor the CCS clock):

Risk factors for severe withdrawal / DT:

Presentation Patterns and Key History

— Autonomic: tachycardia, hypertension, diaphoresis, low-grade fever, mydriasis

— Neuropsychiatric: anxiety, restlessness, insomnia, irritability, tremor

— GI: nausea, vomiting, anorexia

— Severe: hallucinations, seizures, delirium

— Quantify intake: drinks/day × years; ask "When was your last drink?" — anchor your withdrawal clock

— Prior withdrawal episodes, prior DT, prior withdrawal seizures (single most actionable risk factor)

— Prior detox admissions, ICU stays, longest sobriety, treatments tried (naltrexone, AA, residential)

— Co-ingestants: benzodiazepines, opioids, cocaine, methamphetamine — alter both presentation and treatment

— Comorbidities: cirrhosis, pancreatitis, cardiomyopathy, peripheral neuropathy, Wernicke features

— AUDIT-C (≥4 men/≥3 women positive) — quick screen

— CAGE still acceptable but less sensitive

— PAWSS (Prediction of Alcohol Withdrawal Severity Scale): score ≥4 predicts complicated withdrawal — use this to decide between symptom-triggered vs front-loaded regimen

— Alcoholic hallucinosis: clear sensorium, oriented, vitals only mildly abnormal, 12–24 h post-cessation

— DT: clouded sensorium, disoriented, severe autonomic storm, 48–96 h post-cessation

Key distinction: A patient at 18 hours who sees bugs but knows the date, place, and president has hallucinosis, not DT — treat with benzodiazepines and reassess, do not jump to ICU yet. Conversely, a confused, febrile, tachycardic patient on hospital day 3 with no infectious source is DT until proven otherwise.

Core symptom clusters (ask and document explicitly):

History essentials on intake:

Screening tools to apply on admission:

Distinguish hallucinosis from DT (high-yield):

Don't miss collateral history: family, EMS, prior discharge summaries, state prescription drug monitoring program (PDMP), and outpatient pharmacy refills — these often reveal undisclosed use and benzodiazepine co-dependence that changes dosing strategy substantially.

Physical Exam Findings and Hemodynamic Assessment

— Sinus tachycardia (HR 100–140), systolic HTN (often 160–180s), low-grade fever (≤38.3°C), tachypnea

— Persistent fever >38.5°C is NOT withdrawal alone — work up infection (pneumonia, SBP, meningitis, endocarditis)

— Hypotension is a red flag: think GI bleed, sepsis, adrenal insufficiency, or over-sedation

— Coarse, symmetric postural tremor (hands outstretched) — earliest sign

— Hyperreflexia, clonus, mydriasis with sluggish reaction

— Wernicke triad: confusion, ophthalmoplegia (lateral rectus palsy, nystagmus), ataxia — only ~10% have all three; treat empirically

— Korsakoff: anterograde amnesia with confabulation (chronic, less reversible)

— Diaphoresis, flushing, piloerection

— Spider angiomata, palmar erythema, gynecomastia, caput medusae — suggest cirrhosis and alter benzodiazepine choice

— Dupuytren contractures, parotid enlargement, bruising

— Listen for S3 (alcoholic/dilated cardiomyopathy), irregular rhythm (holiday heart → afib)

— Crackles → aspiration pneumonia (frequent comorbid admission diagnosis)

— Hepatomegaly, ascites, RUQ tenderness, epigastric tenderness (pancreatitis), melena on rectal exam

— Calculate shock index (HR/SBP); >1.0 should trigger fluid resuscitation work-up

— Orthostatics if possible — many AUD patients are volume-depleted from vomiting, poor intake, diuresis

CCS pearl: Always order a fingerstick glucose and a full neuro exam before giving benzodiazepines — hypoglycemia and head trauma (subdural in the alcoholic faller) mimic and coexist with withdrawal. A focal neuro deficit mandates non-contrast head CT before sedation, not after.

Vital sign pattern:

Neurologic exam:

General/skin:

Cardiopulmonary:

Abdomen:

Hemodynamic assessment for CCS triage:

Reassess vitals and tremor every time you re-enter the room on the CCS clock — improvement validates your benzodiazepine dose; worsening prompts escalation.

Diagnostic Workup — Initial Labs, Imaging, ECG

— CBC with differential — macrocytosis (MCV >100), thrombocytopenia (marrow suppression vs hypersplenism)

— CMP — AST:ALT >2:1, elevated GGT, hypoglycemia, low albumin, AKI

— Magnesium, phosphorus, ionized calcium — frequently low, must replete to prevent arrhythmia and refractory withdrawal

— Lipase — pancreatitis is a common admission trigger

— PT/INR — synthetic liver function

— Ammonia only if encephalopathy and cirrhosis suspected (not routine)

— Lactate, ABG/VBG — anion gap from alcoholic ketoacidosis (β-hydroxybutyrate predominates)

— Blood alcohol level, urine drug screen, acetaminophen, salicylate — co-ingestion screen

— Urinalysis, blood and urine cultures if febrile

— β-hCG in women of reproductive age before imaging or valproate

— HIV, HCV, HBV serologies — high-yield outpatient handoff item

— Look for prolonged QTc (baseline before ondansetron/haloperidol/methadone), atrial fibrillation (holiday heart), LVH, ischemia

— Repeat after electrolyte repletion

— CXR — aspiration pneumonia, TB, cardiomegaly

— Non-contrast head CT if altered mental status disproportionate to CIWA, focal deficits, seizure, fall, or anticoagulation — subdural hematoma is the classic miss

— RUQ ultrasound only if cholestatic LFTs or suspected ascites/SBP

— Lumbar puncture if fever + meningismus + altered mentation after CT clears mass effect

Step 3 management: Empirically give thiamine 500 mg IV q8h × 3 days before glucose-containing fluids in any malnourished or chronically drinking patient suspected of Wernicke; oral thiamine has poor bioavailability and is inadequate for treatment dosing — reserve PO 100 mg daily for prophylaxis only.

Order set on arrival (CCS first screen):

ECG on arrival:

Imaging selection:

Recheck Mg, K, phos at 6 and 24 hours; persistent hypomagnesemia drives refractory tachycardia and seizure threshold lowering.

Diagnostic Workup — Advanced and Confirmatory Studies

— 10 items, each 0–7 (orientation 0–4); total 0–67

— <8 mild, 8–15 moderate, >15 severe

— Validated only in patients who can communicate — not valid in intubated, demented, aphasic, or non-English speakers without translator; use RASS + objective signs (MINDS or Brief Alcohol Withdrawal Scale) instead

— 10-item admission tool; ≥4 = high risk for complicated withdrawal

— Use to choose front-loaded/scheduled vs symptom-triggered strategy on day 1

— EEG only if seizure was atypical (focal, prolonged, multiple), persistent altered mentation, or status epilepticus — typical withdrawal seizures do not require EEG

— MRI brain if Wernicke is suspected but uncertain — symmetric T2 hyperintensity in mammillary bodies, periaqueductal gray, medial thalami (treat first, image second)

— TTE if cardiomyopathy suspected (low EF, dilated chambers) — schedule outpatient if stable

— FibroScan or hepatology consult for staging chronic liver disease before discharge

— Phosphatidylethanol (PEth) — sensitive marker of drinking in prior 2–3 weeks

— Carbohydrate-deficient transferrin (CDT) — chronic heavy use

— EtG (ethyl glucuronide) urine — drinking in past 3–5 days; useful in monitored sobriety programs

— Quantitative benzodiazepine, barbiturate levels if presentation is atypical

— Osmolar gap if methanol/ethylene glycol suspected (high gap + high anion gap acidosis)

Board pearl: A withdrawal seizure that is focal, prolonged, recurrent within the same admission, or accompanied by persistent postictal deficit is NOT alcohol withdrawal — image the head and obtain EEG. Classic alcohol withdrawal seizures are brief, generalized tonic-clonic, single or in a tight cluster within 6 hours, with full recovery between.

CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised):

PAWSS (Prediction of Alcohol Withdrawal Severity Scale):

When to obtain further studies:

Biomarkers of recent drinking (useful for outpatient handoff, not acute care):

Co-ingestion confirmation:

Risk Stratification and First-Line Management Logic

— Low risk (PAWSS <4, no prior DT/seizure, CIWA <8): symptom-triggered benzodiazepine protocol, ward-level care

— Moderate risk (PAWSS ≥4 OR CIWA 8–15): symptom-triggered with low threshold for scheduled dosing; consider step-down or telemetry

— High risk (prior DT, prior withdrawal seizure, CIWA >15, severe comorbidities): front-loading + scheduled benzodiazepines, telemetry or ICU

— Symptom-triggered (preferred for most): CIWA q1h; benzodiazepine when CIWA ≥8–10; reduces total dose, length of stay, and oversedation

— Front-loaded: large benzodiazepine doses in first 1–4 h to rapidly achieve light sedation, then taper — for high-risk or already severe presentation

— Fixed-schedule taper: reserved for outpatient detox or patients who cannot be reliably assessed (e.g., language barrier, dementia)

— Admit to telemetry; vital signs q1h × 4, then q2h if stable

— CIWA-Ar q1h while symptomatic; q2h then q4h as scores fall <8 sustained

— Lorazepam 2 mg IV q1h PRN CIWA ≥8 (or diazepam/chlordiazepoxide — see chunk 7)

— Thiamine 500 mg IV q8h × 72 h, then 100 mg PO daily

— Folate 1 mg PO daily, multivitamin daily

— MgSO4 2 g IV if Mg <2; KCl if K <4; phosphate repletion as needed

— IV fluids: D5½NS at 100–125 mL/h only after thiamine given, titrate to euvolemia

— DVT prophylaxis (enoxaparin 40 mg SC daily unless contraindicated)

— Diet: regular as tolerated; aspiration precautions if sedated

— Strict I/Os, fall precautions, sitter if agitated, soft restraints only if failing chemical sedation

— Three consecutive CIWA ≥15 despite escalating benzodiazepines

— Need for >20 mg lorazepam-equivalents in 1 h

— Seizure, hypoxia, hemodynamic instability → ICU

CCS pearl: Document the escalation plan in the chart on admission, not when the patient is decompensating at 3 AM. Predefined triggers prevent under-treatment, which is the most common error and the path to DT.

Step 1 — Stratify on admission using PAWSS + history:

Step 2 — Choose dosing strategy:

Step 3 — CCS initial order set (write these together):

Step 4 — Escalation triggers (predefine on day 0):

Pharmacotherapy — First-Line Drug Regimen

— Long-acting (preferred when liver function preserved):

— Diazepam: 10–20 mg IV/PO q1–2h PRN; self-tapers via active metabolites; smooth withdrawal course

— Chlordiazepoxide: 50–100 mg PO q1–2h PRN; oral only; classic outpatient/ward agent

— Short/intermediate-acting (preferred in cirrhosis, elderly, respiratory compromise):

— Lorazepam: 2–4 mg IV/IM/PO q1h PRN — glucuronidated, safe in liver disease (mnemonic: Lorazepam, Oxazepam, Temazepam = "LOT" — no CYP metabolism)

— Oxazepam: 15–30 mg PO q1h PRN

— Diazepam 20 mg PO/IV q1h until CIWA <8 or light sedation, often 60–80 mg total

— Then symptom-triggered only — no scheduled taper needed because of long half-life

— Transition to continuous IV infusion in ICU

— Phenobarbital as adjunct or monotherapy — load 10 mg/kg IV over 30 min, then 130–260 mg q15–30 min; especially useful when benzodiazepine receptor density is downregulated

— Propofol infusion if intubated; provides GABA agonism and NMDA antagonism

— Dexmedetomidine controls autonomic symptoms but does not prevent seizures — adjunct only, never monotherapy

— Ketamine as benzodiazepine-sparing adjunct (NMDA antagonist) in some protocols

— β-blockers/clonidine — mask tachycardia and HTN, can hide withdrawal severity; avoid as monotherapy

— Haloperidol 2.5–5 mg IV for hallucinations/agitation only after adequate benzodiazepine; lowers seizure threshold and prolongs QTc — use cautiously

— Antiepileptics (carbamazepine, gabapentin, valproate) — outpatient/mild withdrawal only; not for inpatient severe disease

— Thiamine 500 mg IV q8h × 3 days, then 250 mg IV/IM daily × 5 days, then 100 mg PO daily

— Folate 1 mg, multivitamin, magnesium, potassium, phosphate repletion

Board pearl: Give thiamine BEFORE glucose to prevent precipitating Wernicke encephalopathy in the thiamine-deplete patient — this is a perennial Step 3 stem.

Benzodiazepines = cornerstone (only therapy proven to reduce DT and seizures):

Front-loading regimen example:

Refractory withdrawal (after ~30–40 mg lorazepam-equivalents/h without control):

Adjuncts (treat symptoms, do not replace benzodiazepines):

Always co-administer:

Procedures and Expanded Pharmacology — ICU-Level Care

— Indications to intubate: inability to protect airway from sedation needs, refractory seizures, severe agitation requiring deep sedation, hypoxemic respiratory failure from aspiration

— Use RSI with etomidate or ketamine + rocuronium; avoid succinylcholine if hyperkalemic from rhabdo

— Post-intubation: propofol infusion 20–80 mcg/kg/min ± fentanyl; titrate to RASS 0 to −1

— Loading dose 10 mg/kg IBW IV over 30 min

— Redose 130–260 mg IV q15–30 min until controlled

— Advantages: long half-life (~80–120 h) self-tapers; works on both GABA and glutamate; effective in benzodiazepine-resistant withdrawal

— Caution: respiratory depression synergistic with benzodiazepines; monitor airway closely

— 0.2–1.5 mcg/kg/h infusion, no bolus (causes hypotension)

— Reduces autonomic symptoms, sympatholytic, preserves respiratory drive

— Useful in patients you want to avoid intubating, but does not prevent seizures or DT — keep benzodiazepines on board

— Lorazepam infusion avoid prolonged use — propylene glycol toxicity (anion gap acidosis, AKI, hyperosmolar) after 48 h or doses >10 mg/h; check osmolar gap daily

— Midazolam infusion accumulates in renal failure (active metabolite α-OH-midazolam)

— Central line for vasopressor or high-volume sedative infusion

— Arterial line for tight hemodynamic monitoring

— Foley for strict I/Os in deeply sedated patient

— Paracentesis if new ascites with fever (rule out SBP)

— NG tube only if obstruction/ileus — avoid routinely (aspiration risk in sedated)

— Flumazenil — can precipitate seizures in benzodiazepine-tolerant patient

— Routine antipsychotic monotherapy — does not treat withdrawal physiology

— Ethanol drips — outdated, narrow therapeutic window, not standard of care

Step 3 management: Suspect propylene glycol toxicity in any patient on lorazepam infusion >48 h with new anion-gap metabolic acidosis and AKI — calculate osmolar gap; switch to midazolam or phenobarbital and the gap closes.

Airway and respiratory management:

Phenobarbital protocol (increasingly first-line in many centers):

Dexmedetomidine:

Continuous infusions in ICU:

Procedures often needed during the admission:

Avoid in withdrawal:

Special Populations — Elderly and Hepatic/Renal Impairment

— Higher baseline cognitive vulnerability; greater risk of delirium, falls, oversedation

— Use lorazepam or oxazepam at half adult doses (lorazepam 0.5–1 mg starting); avoid long-acting diazepam/chlordiazepoxide (accumulation, prolonged sedation, falls)

— Lower CIWA threshold for treatment (start at CIWA ≥6–8) because tolerance is lower and decompensation is faster

— Avoid antihistamines, anticholinergics, and high-dose haloperidol — increase delirium and QT risk

— Reassess fall risk daily; PT/OT consult early

— Reduced metabolism of CYP-dependent benzodiazepines → use LOT drugs (Lorazepam, Oxazepam, Temazepam) which undergo only glucuronidation

— Start lorazepam 1–2 mg (lower if encephalopathy)

— Distinguish withdrawal from hepatic encephalopathy: withdrawal = tremor, tachycardia, diaphoresis, hyperreflexia; HE = asterixis, hyperammonemia, response to lactulose/rifaximin — they can coexist

— Avoid acetaminophen >2 g/day; avoid NSAIDs (variceal bleed, AKI, hepatorenal)

— Consider hepatology consult for transplant evaluation if Child-Pugh B/C

— Lorazepam metabolite (lorazepam-glucuronide) accumulates in severe CKD/dialysis; still preferred but extend dosing intervals

— Avoid midazolam infusions (active renally cleared metabolite)

— Adjust gabapentin, levetiracetam, magnesium dosing for CrCl

— Watch for rhabdomyolysis-induced AKI in agitated, restrained, or seizing patients — check CK, urine myoglobin, aggressive IV fluids

— Extreme thiamine deficiency risk; give 500 mg IV q8h × 72 h without delay

— Refeeding syndrome on day 2–4: monitor phosphate, potassium, magnesium daily; advance calories slowly

— Replete vitamin D, B12 on outpatient handoff labs

Key distinction: In cirrhosis, "LOT" benzodiazepines (Lorazepam, Oxazepam, Temazepam) are safer because they bypass phase I hepatic oxidation — diazepam and chlordiazepoxide accumulate and precipitate hepatic encephalopathy.

Elderly (≥65):

Cirrhosis / hepatic impairment:

Renal impairment:

Malnourished and bariatric patients:

Special Populations — Pregnancy, Adolescents, and Co-occurring Disorders

— Untreated severe withdrawal causes fetal hypoxia, miscarriage, preterm labor, abruption — treat the mother, do not withhold benzodiazepines

— Lorazepam or diazepam are acceptable acutely; risk of neonatal sedation/withdrawal if used near delivery

— Avoid valproate (neural tube defects), phenytoin, carbamazepine in first trimester

— Obstetrics consult on admission, continuous fetal monitoring after 24 weeks gestation

— Screen for IPV, polysubstance use, hepatitis C, HIV, syphilis; arrange MAT (medication-assisted treatment) postpartum

— Naltrexone and acamprosate generally avoided in pregnancy/lactation; behavioral therapy is mainstay

— Rare to need inpatient detox unless heavy chronic use; assess for polysubstance use (cannabis, opioids, stimulants)

— Confidentiality protections vary by state — know your state's minor consent laws for substance use treatment

— Family-based therapy and SBIRT (Screening, Brief Intervention, Referral to Treatment) on discharge

— Manage withdrawals in parallel: benzodiazepines for alcohol, buprenorphine or methadone for opioids

— Beware additive respiratory depression — monitor with continuous pulse oximetry/capnography

— Initiate buprenorphine when COWS ≥8 to avoid precipitated withdrawal

— Cocaine/methamphetamine can mimic withdrawal autonomic features; UDS clarifies

— Avoid β-blockers in acute cocaine intoxication (unopposed α — controversial but classically taught)

— Continue home SSRIs, antipsychotics if able; resume after acute withdrawal stabilizes

— Suicide risk assessment before discharge — AUD doubles suicide risk; ask explicitly

— Trauma-informed care: high prevalence of PTSD, especially in women and veterans

Step 3 management: A pregnant patient in alcohol withdrawal gets benzodiazepines, thiamine, IV fluids, OB consult, and continuous fetal monitoring — withholding treatment to "protect the fetus" causes more harm than the drug exposure. Counsel about neonatal withdrawal monitoring before delivery.

Pregnancy:

Adolescents:

Co-occurring opioid use disorder:

Co-occurring stimulant use:

Co-occurring psychiatric illness:

Complications and Adverse Outcomes

— Onset 48–96 h; mortality 1–5% with treatment, up to 15% untreated

— Features: global confusion, vivid hallucinations, severe autonomic storm (HR >120, SBP >180, fever, profuse diaphoresis), tremor

— Death from arrhythmia, aspiration, hyperthermia, electrolyte disturbance, or comorbid illness (pneumonia, MI, pancreatitis)

— 24–48 h; brief, generalized, single or short cluster

— Status epilepticus is uncommon — if present, image the head and consider alternative etiology

— Phenytoin is NOT effective for alcohol withdrawal seizures (different mechanism); benzodiazepines are

— Confusion, ophthalmoplegia, ataxia (full triad in only ~10%)

— Treat empirically: thiamine 500 mg IV q8h × 3 days — delay leads to irreversible Korsakoff (anterograde amnesia + confabulation)

— Atrial fibrillation (holiday heart) — usually self-resolves with rate control and electrolyte repletion

— Demand ischemia from tachycardia in CAD patients

— Stress cardiomyopathy (Takotsubo) in severe DT

— Aspiration pneumonia — common, often polymicrobial, treat with ampicillin-sulbactam 3 g IV q6h or ceftriaxone + metronidazole

— Acute respiratory failure from oversedation

— Rhabdomyolysis from seizures/agitation/restraints → AKI; aggressive IV fluids

— Refeeding syndrome on day 2–4 — drop in phos/K/Mg, arrhythmia risk

— Hypoglycemia from depleted glycogen stores

— Oversedation, respiratory depression, aspiration from over-aggressive benzodiazepines

— Propylene glycol toxicity from prolonged lorazepam infusion

— Falls in elderly with diazepam/chlordiazepoxide

— QT prolongation from haloperidol/ondansetron stacking

— Against-medical-advice (AMA) discharge

— Loss of housing, employment, custody during admission

Board pearl: A patient on hospital day 3 with fever, tachycardia, and confusion has DT OR an infection — work up both simultaneously, don't anchor on one. Blood cultures, CXR, UA, lactate, and lumbar puncture if meningismus, while continuing benzodiazepines.

Delirium tremens (DT):

Withdrawal seizures:

Wernicke encephalopathy:

Cardiovascular:

Pulmonary:

Renal/Metabolic:

Iatrogenic:

Psychosocial:

When to Escalate — ICU, Consultation, and Triage

— Refractory CIWA ≥15 despite escalating benzodiazepines (>20–30 mg lorazepam-equivalents/h)

— Need for continuous IV sedation infusion (lorazepam, midazolam, propofol, dexmedetomidine)

— Need for intubation or airway protection

— Seizure recurrence despite adequate benzodiazepines

— Hemodynamic instability (SBP <90, HR >140 sustained, arrhythmia)

— Severe metabolic derangement (pH <7.2, K <3, severe rhabdomyolysis)

— Coexisting critical illness (severe pancreatitis, GI bleed with shock, sepsis, MI)

— CIWA 10–20 requiring frequent dosing

— History of DT or withdrawal seizure but currently controlled

— Atrial fibrillation requiring rate control

— Significant electrolyte derangement requiring monitored repletion

— CIWA <10, no seizure history, stable vitals, adequate response to PRN dosing

— Psychiatry / addiction medicine: for MAT initiation (naltrexone, acamprosate, disulfiram), motivational interviewing, dual diagnosis

— Social work / case management: housing, insurance, transportation to follow-up, MAT pharmacy access

— Hepatology: Child-Pugh B/C, ascites, varices, transplant evaluation

— Cardiology: new afib, suspected cardiomyopathy

— Nutrition: refeeding monitoring, vitamin repletion plan

— Pharmacy: review home medications, drug interactions on discharge

— Chaplaincy / peer recovery support: when appropriate and patient-requested

— CIWA <8 for ≥24 hours without PRN benzodiazepine

— Stable vitals, tolerating PO, ambulating

— Outpatient follow-up arranged within 7 days

— MAT initiated or refused after counseling (documented)

— Naloxone prescribed if any opioid co-use

CCS pearl: Move the patient through care levels deliberately — ICU → step-down → floor → discharge. On the CCS interface, advance the clock after each transfer and recheck vitals, CIWA, electrolytes, and medication response before the next decision point.

Indications for ICU transfer:

Telemetry / step-down criteria:

Floor / general ward:

Consults on the CCS screen:

Discharge readiness criteria:

Key Differentials — Same-Category (Withdrawal/Toxicology) Causes

— Clinically indistinguishable from alcohol withdrawal — tremor, autonomic storm, seizures, delirium

— Onset varies by half-life: alprazolam 1–2 days, diazepam/clonazepam 3–7 days

— Treatment: long taper with the same class (diazepam or phenobarbital); cross-tolerance allows benzodiazepine substitution

— Always ask about benzodiazepine use in any AUD patient — co-dependence is common and changes prognosis

— Yawning, lacrimation, rhinorrhea, mydriasis, piloerection, diarrhea, abdominal cramping, myalgia

— Not life-threatening in healthy adults (unlike alcohol/sedative withdrawal)

— Treat with buprenorphine (when COWS ≥8) or methadone; supportive care with clonidine, loperamide, ondansetron

— Hypersomnia, depression, increased appetite, anhedonia ("crash")

— No autonomic hyperactivity; supportive care, suicide screen

— Irritability, insomnia, decreased appetite, mild tremor; mild and self-limited

— Often coexists in admitted alcoholics; offer nicotine replacement (patch + gum/lozenge) on admission — improves overall comfort and reduces against-medical-advice discharges

— "Hot as a hare, dry as a bone, red as a beet, blind as a bat, mad as a hatter" — dry skin distinguishes from alcohol withdrawal's diaphoresis

— Clonus, hyperreflexia, hyperthermia, recent SSRI/MAOI/tramadol exposure

— Clonus is more prominent than tremor; treat with cyproheptadine, discontinue offending agent

— Lead-pipe rigidity, hyperthermia, autonomic instability, recent antipsychotic exposure

— CK markedly elevated; treat with dantrolene, bromocriptine

Key distinction: Diaphoresis + tremor + tachycardia + recent cessation of drinking = alcohol withdrawal. Dry skin + mydriasis + urinary retention + delirium = anticholinergic toxicity. The skin tells you the diagnosis in 5 seconds at the bedside.

Sedative-hypnotic withdrawal (benzodiazepine, barbiturate, GHB, "Z-drugs"):

Opioid withdrawal:

Stimulant withdrawal (cocaine, methamphetamine):

Cannabis withdrawal:

Nicotine withdrawal:

Anticholinergic toxicity / withdrawal:

Serotonin syndrome:

Neuroleptic malignant syndrome (NMS):

Key Differentials — Other-Category Mimics

— Fever, tachycardia, AMS, elevated lactate — overlaps significantly with DT

— Always send blood cultures, UA, lactate, CXR; start empiric antibiotics if qSOFA ≥2 or shock — do not delay antibiotics waiting to "rule out withdrawal"

— Tachycardia, tremor, hyperthermia, AMS, GI symptoms

— Often Graves' history, goiter, ophthalmopathy; TSH suppressed, free T4/T3 elevated

— Treat with β-blockers, PTU/methimazole, iodine, steroids

— Episodic HTN, headache, palpitations, diaphoresis

— Plasma metanephrines for screen; CT abdomen if positive

— Fever, AMS, headache, meningismus, photophobia

— LP after CT if focal signs or papilledema; empiric ceftriaxone + vancomycin + ampicillin (if >50) + acyclovir until cleared

— High prevalence in alcoholic fallers, anticoagulated patients

— Focal deficits, persistent altered mentation disproportionate to CIWA

— Non-contrast head CT — classic missed diagnosis

— Asterixis (not tremor), hyperammonemia, cirrhosis stigmata

— Precipitated by GI bleed, infection, electrolyte imbalance, constipation

— Treat with lactulose (titrate to 3 stools/day) and rifaximin 550 mg BID

— Fingerstick at every bedside encounter; D50 if <70 with symptoms — give after thiamine

— Tachycardia and chest pain in withdrawal can mask demand ischemia

— ECG and troponin if persistent tachycardia or chest pain

— SBP >180 with end-organ dysfunction; visual changes, seizure → MRI for PRES

— Medication history is the differentiator

Step 3 management: A patient with known AUD admitted for "withdrawal" who has persistent confusion after 48 h of adequate benzodiazepines needs a broad reassessment: head CT, LP if febrile, ammonia, lactate, cultures, ECG, troponin, and a thoughtful medication review — anchoring on withdrawal causes deaths.

Sepsis:

Thyroid storm:

Pheochromocytoma:

CNS infection (meningitis, encephalitis):

Intracranial hemorrhage / subdural hematoma:

Hepatic encephalopathy:

Hypoglycemia:

Cardiac arrhythmia / MI:

Hypertensive emergency / PRES:

Serotonin syndrome / NMS:

Secondary Prevention, Discharge Medications, and Long-Term Plan

— Naltrexone 50 mg PO daily OR 380 mg IM monthly (Vivitrol) — first-line for most; reduces heavy drinking days; avoid in acute hepatitis (AST/ALT >5× ULN) or current opioid use (precipitates withdrawal — requires 7–10 day opioid-free interval)

— Acamprosate 666 mg PO TID — first-line in liver disease or recent opioids; renally cleared (avoid CrCl <30); maintains abstinence

— Disulfiram 250 mg PO daily — only in highly motivated patients with supervised administration; causes severe reaction with ethanol; contraindicated in CAD, psychosis, pregnancy

— Off-label adjuncts: gabapentin (300–600 mg TID — reduces cravings, helps insomnia), topiramate (titrate to 200–300 mg/day — reduces heavy drinking)

— Thiamine 100 mg PO daily, folate 1 mg PO daily, multivitamin for at least 30 days

— Continue any hepatitis or cirrhosis-related meds (rifaximin, lactulose, propranolol for varices, spironolactone/furosemide for ascites)

— Avoid prescribing benzodiazepines on discharge — high misuse and overdose risk; taper completes inpatient

— Naloxone Rx if any opioid co-use, household opioid exposure, or history of overdose

— Nicotine replacement continuation

— Hepatitis A and B (if non-immune)

— Pneumococcal (PCV20 or PCV15 + PPSV23) — chronic liver disease indication

— Influenza, COVID, Tdap as due

— Referral to outpatient addiction medicine / intensive outpatient program (IOP)

— Mutual help groups: AA, SMART Recovery, Refuge Recovery

— Cognitive behavioral therapy, motivational enhancement therapy, contingency management

— Peer recovery coach if available

— Housing, employment, transportation, insurance — case management referral

— Domestic violence and child welfare screening

— Driving counseling: many states require physician reporting after withdrawal seizure

Board pearl: Naltrexone IM monthly doubles adherence vs daily oral therapy in real-world studies — offer it at discharge for any patient with AUD who is not actively using opioids and lacks acute hepatitis. Start it before they leave the hospital.

Initiate medication for AUD (MAT) BEFORE discharge — single best evidence-based intervention:

Discharge medication review:

Vaccinations before discharge:

Behavioral and recovery support:

Social determinants:

Follow-Up, Monitoring, and Rehabilitation Plan

— Within 48–72 hours: phone call from case manager or nurse navigator — confirms medication pickup, screens for relapse, reinforces follow-up

— Within 7 days: primary care or addiction medicine visit — review MAT tolerance, labs, mood, cravings

— 2 weeks: repeat CMP (LFTs on naltrexone), CBC, magnesium

— 4 weeks: addiction medicine follow-up; consider second Vivitrol injection

— 3 months: PEth or CDT to verify abstinence if appropriate; reassess MAT

— 6 and 12 months: ongoing PCP visits; screen for cardiomyopathy (echo if symptoms), HCC surveillance with US ± AFP q6 months in cirrhosis

— Naltrexone: LFTs at baseline, 1 month, then q3–6 months

— Acamprosate: renal function at baseline and periodically

— Disulfiram: LFTs at baseline, 2 weeks, 6 weeks, then q6 months

— Quantify recent drinking; use validated tool (AUDIT-C) at each visit

— Address triggers, coping strategies, social environment

— Reinforce mutual help group attendance

— Address comorbid depression, anxiety, PTSD — co-treat

— Residential treatment (28-day, longer) for those who fail outpatient or have unsafe home environment

— Partial hospitalization / IOP for moderate severity

— Sober living homes post-residential

— Vocational rehabilitation if employment lost

— Driver evaluation; DMV reporting requirements vary by state after withdrawal seizure

— Recognizing relapse signs

— Naloxone training if opioid co-use

— Al-Anon for family members

— Liver: FibroScan, HCC screen

— Cardiac: echo if symptoms or known cardiomyopathy

— Neuro: cognitive testing if Korsakoff suspected

— Nutrition: vitamin D, B12, folate; bone density in chronic users

CCS pearl: A 7-day follow-up appointment scheduled before discharge is among the strongest predictors of sustained sobriety and reduces 30-day readmission — make the appointment, don't just hand the patient a phone number.

Post-discharge cadence (write this in the discharge summary explicitly):

Lab monitoring on MAT:

Counseling at every visit:

Rehabilitation considerations:

Family and caregiver education:

Surveillance for sequelae of chronic use:

Ethical, Legal, and Patient Safety Considerations

— A patient in active withdrawal is NOT capacitated to refuse treatment for that withdrawal — sedation, fluids, and thiamine may proceed under implied consent / emergency exception

— Reassess capacity once stabilized; document the four pillars (understand, appreciate, reason, communicate choice)

— Use surrogate decision-maker per state hierarchy if persistent incapacity (spouse → adult child → parent → sibling)

— Common in AUD; assess capacity carefully — withdrawal symptoms can impair capacity transiently

— Document the discussion: risks (seizure, DT, death), alternatives, patient's understanding

— Offer harm reduction: thiamine prescription, naloxone, follow-up appointment, return precautions

— AMA does not invalidate insurance coverage in most cases (a common myth)

— Withdrawal seizure → DMV reporting in many states (CA, OR, NV, NJ, PA, others)

— Child abuse/neglect if minor children in the home and unsafe environment

— Elder abuse suspected

— Intimate partner violence — offer resources; reporting is generally not mandatory for competent adults except in specific states

— 42 CFR Part 2 governs federally-funded substance use treatment records — stricter than HIPAA; written specific consent required for disclosure even to other clinicians

— Updates in 2024 partially aligned Part 2 with HIPAA but core protections remain

— Chemical sedation preferred over physical restraints

— Physical restraints require order with renewal q4h adult / q1–2h pediatric, continuous monitoring, and least-restrictive principle

— Document rationale, alternatives tried, and plan to discontinue

— Transitions (ED → floor, floor → ICU, hospital → home) are highest-risk moments for under-treatment and oversedation

— Use structured handoff (I-PASS, SBAR) and explicitly communicate withdrawal status, last benzodiazepine dose, CIWA trend, and escalation plan

— Document neutrally ("patient with alcohol use disorder"), avoid "alcoholic" or "drunk"

— Address implicit bias in pain management and follow-up

Step 3 management: A patient in delirium tremens demanding to leave AMA lacks decisional capacity by virtue of the delirium itself — you may detain and treat under emergency doctrine; obtain a psychiatric or capacity consult and document carefully. Capacity is decision-specific and reassessed dynamically.

Capacity and informed refusal:

Against-medical-advice (AMA) discharge:

Mandatory reporting (state-specific, know your jurisdiction):

Confidentiality:

Restraints:

Patient safety / handoff:

Stigma and bias:

High-Yield Associations and Rapid-Fire Clinical Facts

— 6–12 h: minor withdrawal (tremor, anxiety)

— 12–24 h: hallucinosis (clear sensorium)

— 24–48 h: withdrawal seizures

— 48–96 h: delirium tremens

— AST:ALT >2:1 = alcoholic liver disease

— MCV >100 = chronic alcohol use (or B12/folate deficiency)

— GGT elevated, often isolated, in heavy drinkers

— Anion gap acidosis with normal lactate and positive serum ketones → alcoholic ketoacidosis (β-hydroxybutyrate predominates; treat with dextrose + saline + thiamine)

— LOT (Lorazepam, Oxazepam, Temazepam) — phase II glucuronidation, safe in cirrhosis

— Phenytoin doesn't prevent withdrawal seizures — only benzodiazepines do

— Flumazenil is contraindicated — precipitates seizures

— Thiamine before glucose to prevent Wernicke

— Diazepam IV onset ~5 min; lorazepam IV onset ~15–20 min; choose based on rapidity needed

— Holiday heart = atrial fibrillation after binge, resolves with sobriety + rate control

— Alcoholic dilated cardiomyopathy reversible with sustained abstinence in many cases

— Wernicke encephalopathy triad: confusion, ophthalmoplegia, ataxia

— Korsakoff: anterograde amnesia + confabulation, often irreversible

— Marchiafava-Bignami: corpus callosum demyelination, rare

— Central pontine myelinolysis: over-rapid correction of hyponatremia in alcoholics

— Maddrey discriminant function ≥32 in alcoholic hepatitis → consider steroids (prednisolone 40 mg) if no contraindication; reassess with Lille score at day 7

— Child-Pugh and MELD for cirrhosis prognosis

— Thiamine 500 mg IV q8h × 3 days

— Folate 1 mg

— Multivitamin

— Repletion of Mg, K, phos

— Naltrexone: reduces heavy drinking; oral or monthly IM

— Acamprosate: maintains abstinence; TID dosing

— Disulfiram: aversive; requires supervision and motivation

— Gabapentin/topiramate: off-label, useful adjuncts

Board pearl: A patient with confusion, lateral rectus palsy, and ataxic gait who recently received D5 IV fluids without thiamine has iatrogenic Wernicke encephalopathy — give thiamine 500 mg IV immediately and document the medication error.

Timeline mnemonic — "6, 12, 24, 48":

Lab snapshots:

Drug pearls:

Cardiac:

Neurologic:

Hepatic:

Vitamins to give every alcoholic on admission:

MAT comparisons:

Board Question Stem Patterns

— Patient admitted for cholecystectomy, on POD2 develops tremor, tachycardia 120s, BP 170/100, diaphoresis, anxiety. AUD history elicited on re-questioning.

— Answer: initiate symptom-triggered lorazepam, thiamine, electrolyte repletion; CIWA monitoring q1h.

— Patient with cirrhosis, last drink 3 days ago, now confused with tremor and BP 180/100.

— Distinguish withdrawal from hepatic encephalopathy. Asterixis + ammonia → HE. Tremor + diaphoresis + tachycardia → withdrawal. Often both — treat with lorazepam (not diazepam) plus lactulose/rifaximin.

— Patient given IV dextrose in ED for hypoglycemia, then becomes confused with ophthalmoplegia.

— Answer: thiamine 500 mg IV immediately; this is iatrogenic Wernicke.

— Patient receiving lorazepam 4 mg IV q1h with CIWA persistently >20, now seizing.

— Answer: transfer to ICU, load phenobarbital, prepare to intubate, evaluate for missed diagnosis (subdural, infection).

— Patient demanding discharge during active withdrawal.

— Answer: patient lacks capacity due to delirium; treat under emergency exception, document, obtain psychiatric consult.

— Hospital day 3, fever 39, HR 130, confusion, leukocytosis.

— Answer: work up both — cultures, CXR, UA, lactate, empiric antibiotics if qSOFA ≥2; continue benzodiazepines.

— Patient with cirrhosis AST 300 wants to stop drinking.

— Answer: acamprosate (renally cleared, safe in liver disease); avoid naltrexone if AST >5× ULN.

— If on chronic opioids: avoid naltrexone, use acamprosate or gabapentin.

— 28-week pregnant patient with severe withdrawal.

— Answer: treat with benzodiazepines (lorazepam), thiamine, OB consult, continuous fetal monitoring.

— ICU patient on lorazepam infusion 72 h, new anion gap acidosis and AKI.

— Answer: check osmolar gap, switch to phenobarbital.

— CIWA <8 × 24 hours, tolerating PO, MAT initiated → discharge with 7-day follow-up.

Key distinction: Step 3 stems often pivot on medication choice in special populations (cirrhosis → LOT; pregnancy → benzodiazepine yes; opioid co-use → avoid naltrexone) and on management decisions (escalate, consult, discharge cadence) rather than diagnosis alone.

Stem 1 — "Postoperative day 2 tachycardia":

Stem 2 — "Cirrhotic with altered mentation":

Stem 3 — "Wernicke in disguise":

Stem 4 — "Refractory withdrawal":

Stem 5 — "AMA with capacity question":

Stem 6 — "DT vs sepsis":

Stem 7 — "Best medication for MAT":

Stem 8 — "Pregnant withdrawal":

Stem 9 — "Propylene glycol":

Stem 10 — "Discharge timing":

One-Line Recap

Alcohol withdrawal is a predictable, time-dependent hyperadrenergic syndrome best managed with symptom-triggered benzodiazepines (LOT agents in cirrhosis), empiric IV thiamine before glucose, aggressive electrolyte repletion, vigilant escalation criteria, and discharge initiation of medication for AUD (naltrexone, acamprosate, or disulfiram) plus a scheduled 7-day follow-up.

— Tremor and autonomic symptoms at 6–12 h; hallucinosis at 12–24 h; seizures at 24–48 h; DT at 48–96 h

— CIWA-Ar for assessment in communicative patients; PAWSS ≥4 predicts complicated course

— Always rule out infection, head trauma, hepatic encephalopathy, and hypoglycemia before anchoring on withdrawal

— Admit telemetry → CIWA q1h → lorazepam 2 mg IV PRN CIWA ≥8 → thiamine 500 mg IV q8h → folate, multivitamin → repletion of Mg/K/phos → predefine escalation triggers

— Refractory → phenobarbital load + ICU + propofol/dexmedetomidine adjuncts

— Avoid flumazenil, phenytoin monotherapy, and prolonged lorazepam infusions

— Cirrhosis → LOT benzodiazepines

— Pregnancy → treat aggressively, OB consult, fetal monitoring

— Elderly → half doses of short-acting benzodiazepines

— Opioid co-use → buprenorphine + benzodiazepine; avoid naltrexone for MAT

— Naltrexone IM monthly (best adherence) or acamprosate; disulfiram if motivated

— Thiamine, folate, multivitamin × 30 days

— Hepatitis A/B, pneumococcal vaccines; naloxone Rx if any opioid exposure

— 7-day PCP/addiction follow-up scheduled before discharge; case manager call at 48–72 h

— Connect to AA/IOP; screen suicide risk; document capacity; respect 42 CFR Part 2

Final board pearl: The two interventions that move the survival needle most in hospitalized alcohol withdrawal are early adequate benzodiazepine dosing (don't under-treat) and early empiric IV thiamine (don't forget it) — everything else is supportive. The intervention that moves the outpatient needle most is starting MAT before the patient walks out the door.

Diagnosis & timeline:

Acute management (CCS skeleton):

Special populations:

Discharge bundle: