Analgesia, sedation and delirium

Alcohol withdrawal and delirium tremens

Reviewed Nov 2026·1 references
New· views rounded down, updated weekly

Recognise withdrawal timelines, use CIWA-Ar and symptom-triggered or front-loaded benzodiazepines, add phenobarbital for resistance, give thiamine first and treat complications.

Definition
Alcohol withdrawal: tremor, anxiety, sweating, tachycardia 6-24 h after the last drink; seizures 6-48 h; hallucinosis 12-48 h; delirium tremens (DTs) 48-96 h with confusion, autonomic instability and hyperthermia (mortality up to 5% treated).

At the bedside

  1. 1

    Assess

    CIWA-Ar (if able to communicate; > 15 severe) or RASS/MINDS in ICU; history of DTs or withdrawal seizures predicts severe course; check glucose, electrolytes (Mg, PO4, K), LFT, CT head after fall/first seizure.

  2. 2

    Thiamine before glucose

    Thiamine 200-500 mg IV three times daily for suspected Wernicke (confusion, ataxia, ophthalmoplegia - any one in at-risk patient), otherwise 100-200 mg daily.

  3. 3

    Benzodiazepines

    Symptom-triggered or front-loaded diazepam (10-20 mg every 1-2 h orally, or 5-10 mg IV every 5-10 min for severe), lorazepam in liver failure/elderly; target light sedation (RASS 0 to -1).

  4. 4

    Resistant withdrawal

    High benzodiazepine requirements (e.g. diazepam > 50-100 mg/h): phenobarbital 10 mg/kg IV or incremental doses; propofol or dexmedetomidine as adjuncts in ventilated patients (dexmedetomidine does not prevent seizures).

  5. 5

    Supportive

    Fluids, correct Mg/K/PO4 (refeeding risk), cooling for hyperthermia, nutrition; avoid antipsychotics as monotherapy (lower seizure threshold).

  6. 6

    After recovery

    Brief intervention, de-addiction referral, consider naltrexone/acamprosate (if liver allows) or baclofen in cirrhosis.

Severe withdrawal/DTs

Diazepam

IV
Dose
5-10 mg every 5-10 min until calm (light sedation)
Worked example
Typical DTs: 10 mg IV, repeat every 10 min; total may exceed 100 mg in first hours

Liver failure / elderly

Lorazepam

IV
Dose
1-4 mg every 5-15 min as needed

Benzodiazepine-resistant

Phenobarbital

IV
Dose
10 mg/kg (ideal body weight) over 30 min
Worked example
IBW 65 kg: 650 mg in 100 mL NS over 30 min; monitor airway

Wernicke treatment

Thiamine

IV
Dose
200-500 mg three times daily for 3-5 days
Red flag · call your senior now
Fever, tachycardia > 120, agitation and confusion 2-4 days after admission in a drinker: delirium tremens - ICU care.
Pitfall
Giving dextrose before thiamine in malnourished drinkers (may precipitate Wernicke).
Pitfall
Treating DTs with haloperidol alone.
Pitfall
Missing concurrent sepsis, pancreatitis, head injury or hepatic encephalopathy.
Pearl
Admission to ICU for an unrelated problem (trauma, surgery, pneumonia) is a common setting for unrecognised withdrawal - take an alcohol history from family.

References

  1. 1

    The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med 2020;14(3S Suppl 1):1-72.

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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.