# Alcohol Withdrawal
-- ABC: calculate PAWSS; does the patient need ICU for checks q1-2, CIWA >20, already in DTs, or concern about airway protection?
-- Chart Check: prior admissions, seizures, intubations
-- HPI Intake: quantity and type of EtOH, last drink, hx of seizure, ICU, intubation, DTs, hx patient-initiated discharge, other drug use
-- Can't Miss: seizure, delirium tremens
-- Admission Orders: CIWA at least q4
-- Initial Treatment to Consider: give IV thiamine if c/f Wernicke's, D5LR if c/f ketoacidosis; decide on PRN vs standing benzos
-- History: *** quantity and type of EtOH, last drink, hx of seizure, ICU, intubation, DTs, hx patient-initiated discharge, other drug use
-- Clinical/Exam: *** tremors, sweats, tachy, HTN, headache, anxiety, seizure, hallucinations (visual/tactile > auditory), DT’s is disorientation, hyperactivity, hallucinations
-- Data: *** CBC, CMP, CK, UDS, serum EtOH
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
-- Labs - CBC, CMP, CK, UDS, serum EtOH
-- IV thiamine 200-500mg IV TID for 4-7 days if c/f Wernicke’s, D5LR if c/f ketoacidosis
-- CIWA q2-4 with *** (PRN vs standing; benzo, phenobarb) protocol
-- Folate 1mg daily, multivitamin daily
-- Consider initiating naltrexone 25mg PO daily, acamprosate 666mg TID
-- Recommend AA
PDF coming soon!
Alcohol withdrawal can be life-threatening. Those at risk for severe withdrawal (largely based on a known history of previous severe withdrawal) should have standing benzos ordered, otherwise order them PRN based on CIWA score. It doesn't hurt to give IV thiamine if there is concern for Wernicke encephalopathy. Chronic changes of alcohol use may also include cytopenias and decreased renal tubule and GI absorption leading to low K, Mag, Ca, Phos, and Vitamin D.