Diagnosis and Management of Emergency Department Patients With Alcohol Withdrawal Syndrome (Substance Use Disorders CME and Pharmacology CME)

Table of Contents

 

About This Issue

ED patients who present with symptoms of alcohol withdrawal – or who develop it during an ED stay – require aggressive treatment and monitoring in order to prevent neuropsychiatric complications that can lead to death. This issue discusses the typical timing of symptoms of alcohol withdrawal syndrome (AWS) and how to begin individualized management, from symptom control to referral resources for alcohol use disorder. In this issue, you will learn:

How the patient’s history of alcohol use, cessation, and previous alcohol withdrawal can help determine where they fall on the timeline of symptoms.

What the criteria and risk factors for complicated AWS are, and the medications that can blunt symptoms.

How to use scoring tools for AWS, including the CIWA-Ar, BAWS, and PAWSS.

Choosing the best benzodiazepine for symptom-triggered treatment: shorter time to onset versus longer half-life, and cautions for intubated patients and those with liver disease.

Recommendations on the use of phenobarbital for AWS, with or without benzodiazepine.

The current evidence on the use of ketamine, gabapentin, acamprosate, magnesium, and antiseizure medications.

Discharge with detoxification referral, admission to inpatient treatment, or to ICU? How to track symptoms for the best outcome.

What emergency clinicians need to know about medications for AWS prevention, prophylaxis, and outpatient tapering, and whether treatment for alcohol use disorder should begin in the ED.

1. About This Issue
2. Acknowledgement
3. Abstract
4. Case Presentations
5. Introduction
6. Critical Appraisal of the Literature
7. Etiology and Pathophysiology
8. Differential Diagnosis
9. Prehospital Care
   1. Sobering Centers
10. Emergency Department Evaluation
    1. History
    2. Physical Examination
       1. Scoring the Severity of Alcohol Withdrawal
       2. Complicated Alcohol Withdrawal
          1. Alcohol Withdrawal Hallucinosis
          2. Alcohol Withdrawal Seizures
          3. Delirium Tremens
11. Diagnostic Studies
    1. Laboratory Studies
    2. Electrocardiogram
    3. Imaging Studies
12. Treatment
    1. Treatment Strategies for Alcohol Withdrawal Syndrome
    2. Benzodiazepines
    3. Phenobarbital
    4. Adjunctive Therapy
    5. Prevention and Prophylaxis
13. Special Populations
    1. The Complicated Withdrawal Patient
    2. The Intubated Patient
    3. The Patient With End-Stage Liver Disease
    4. The Pregnant Patient
14. Controversies and Cutting Edge
    1. N-Methyl-D-Aspartate Receptor Antagonists
       1. Ketamine
       2. Acamprosate
       3. Magnesium
    2. Gabapentin
    3. Antiseizure Medications
       1. Dexmedetomidine
       2. Baclofen
15. Disposition
16. 5 Things That Will Change Your Practice
17. Risk Management Pitfalls for Emergency Department Patients With Alcohol Withdrawal Syndrome
18. Summary
19. Time- and Cost-Effective Strategies
20. Case Conclusions
21. Clinical Pathway for Emergency Department Management of Alcohol Withdrawal Syndrome
22. Tables and Figures
23. References

Abstract

Alcohol withdrawal syndrome is a constellation of symptoms and signs resulting from the abrupt decrease or cessation of heavy alcohol use. Complications of alcohol withdrawal syndrome present significant dangers for patient morbidity and mortality, as well as burdens on emergency department resources. This review presents an overview of the pathophysiology of alcohol withdrawal syndrome and a systematic approach for management in the emergency department. Current evidence on treatment regimens and adjunctive therapies is reviewed, and recommendations for management of patients with alcohol use disorders are discussed.

Case Presentations

A 42-year-old man presents to the emergency department by ambulance with a seizure witnessed by bystanders…

• He said he consumes about a fifth (750 mL) of whisky daily, and he says he has a history of alcohol withdrawal seizures. His last drink was about 24 hours ago.
• EMS checked his fingerstick blood glucose, which was normal, and administered 1 liter of IV 0.9% saline.
• His heart rate is 120 beats/min and his blood pressure is 163/92 mm Hg. He is oriented, but tremulous, anxious, and sweating.
• You consider your options to help control his symptoms quickly and prevent a repeat seizure...

52-year-old man presents altered to the ED, but now he is attempting to leave…

• EMS transported him to the ED after reports of a man stumbling into the middle of traffic.
• You see a malnourished-looking man attempting to get out of the stretcher, swaying back and forth.
• His vital signs are unattainable, but he appears diaphoretic, altered, and his extremities are hot to the touch. He is moaning, “No, no, no,” and grasping at the air.
• You note in his records that he was seen for alcohol intoxication and a fall 4 days prior. His head and cervical spine CT scans were negative.
• You consider whether this patient has capacity, and what your best next steps would be...

30-year old woman is signed out to you for time to metabolize alcohol …

• She says she normally imbibes 2 bottles of wine a day, and her last drink was about 12 hours ago.
• She has a history of withdrawal, but no hospitalizations for seizures or hallucinations.
• After 4 hours into your shift, the nurse informs you that the patient’s CIWA-Ar is 7, she is feeling anxious, and wishes to discuss detoxification options with you. To prepare for the discussion, you review the options for outpatient care resources you can offer, in order to prevent further withdrawal, and control her cravings...

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Clinical Pathway for Emergency Department Management of Alcohol Withdrawal Syndrome

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Strayer RJ, Friedman BW, Haroz R, et al. Emergency department management of patients with alcohol intoxication, alcohol withdrawal, and alcohol use disorder: a white paper prepared for the American Academy of Emergency Medicine. J Emerg Med. 2023;64(4):517-540. (White paper/clinical guidelines) DOI: 10.1016/j.jemermed.2023.01.010

4. * Kast KA, Sidelnik SA, Nejad SH, et al. Management of alcohol withdrawal syndromes in general hospital settings. BMJ. 2025;388:e080461. (Review) DOI: 10.1136/bmj-2024-080461

7. * The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med. 2020;14(3S Suppl 1):1-72. (Clinical practice guidelines) DOI: 10.1097/ADM.0000000000000668

8. * Borgundvaag B, Bellolio F, Miles I, et al. Guidelines for reasonable and appropriate care in the emergency department (GRACE-4): alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department. Acad Emerg Med. 2024;31(5):425-455. (Clinical practice guidelines) DOI: 10.1111/acem.14911

71. * Pourmand A, AlRemeithi R, Kartiko S, et al. Evaluation of phenobarbital based approach in treating patient with alcohol withdrawal syndrome: a systematic review and meta-analysis. Am J Emerg Med. 2023;69:65-75. (Systematic review and meta-analysis; 12 articles, 1934 patients) DOI: 10.1016/j.ajem.2023.04.002

85. * Wolf C, Curry A, Nacht J, et al. Management of alcohol withdrawal in the emergency department: current perspectives. Open Access Emerg Med. 2020;12:53-65. (Review) DOI: 10.2147/OAEM.S235288

106. *McPheeters M, O’Connor EA, Riley S, et al. Pharmacotherapy for alcohol use disorder: a systematic review and meta-analysis. JAMA. 2023;330(17):1653-1665. (Systematic review and meta-analysis; 118 articles; 20,976 patients) DOI: 10.1001/jama.2023.19761

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Keywords: ethanol, tachycardia, withdrawal, hypertension, tremor, diaphoresis, benzodiazepine, CIWA-Ar, hallucinosis, seizure, delirium, kindling, phenobarbital, ketamine, gabapentin, anti-craving