Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives

Figures & data

Figure 1 Stages of alcohol withdrawal syndrome.

Figure 2 Prediction of Alcohol Withdrawal Severity Scale

Notes: Reproduced with permissin from Oxford University Press. Maldonado Jet al. Prospective Validation of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in medically ill inpatients: a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol Alcoholism. 2015;50(5):509–518.²¹Abbreviations: BAL, blood alcohol level; PAWSS, Prediction of Alcohol Withdrawal Severity Scale; AA, Alcoholics Anonymous; AWS, alcohol withdrawal syndrome.

Table 1 Characteristics of Benzodiazepines Used for AWS

	Available Route of Dose	Relative Equivalent Potency	Onset of Action (After Oral Administration)	Peak Blood Levels (Hours)	Half-Life (Hours)	Duration of Action	Metabolism
Chlordiazepoxide	PO	10	Intermediate	0.5–2	24–48	Long	Hepatic
Clorazepate	PO, IM	7.5	Rapid	0.5–2	48 (active metabolite)	Short	Hepatic
Diazepam	PO, IM, IV, PR	5	Rapid	Oral: 0.25–2.5 IM: 1 IV: 0.01	30–60	Long	Hepatic
Lorazepam	PO, IM, IV	1	Intermediate	Oral: 2 IM: ≤3	12–18	Short to medium	Hepatic
Midazolam	PO, IM, IV	2	Rapid	Oral: 0.2–2.5 IM: 0.5–1	2–7	Short	Hepatic, gut

Notes: Data from Botswick J.⁸⁷

Abbreviations: AWS, alcohol withdrawal syndrome; PO, per os; IM, intramuscularly; IV, intravenously; PR, per rectum.

Table 2 Sample Alcohol Withdrawal Protocols

Symptom-triggered benzodiazepines	Oxazepam 15mg (or diazepam 10mg) q30m prn CIWA 8–15 and 30mg (diazepam 20mg) q30m prn CIWA >15 for 48 hours^Citation88 Oxazepam 30mg (diazepam 20mg) q1h prn CIWA ≥10^Citation61 Lorazepam 2mg q2h prn CIWA >15, q6h prn CIWA 8–15, stop when CIWA <8 for 24h^Citation89
Fixed benzodiazepine taper	Chlordiazepoxide 50mg po q6h x24h then 25mg po q6h x 48h^Citation90 Diazepam 10mg po q6h x24h then 5mg po q6h x48h^Citation90
Novel anticonvulsants	Carbamazepine 200mg q6h x7d^Citation91 Divalproex 500mg po q8h x7d (adjunctive)^Citation61 Gabapentin 400mg q8h x3d then 400mg q12h x1d^Citation92 Gabapentin 1200mg loading then 800mg q8h x4d then 600mg q8h x2d then 300mg q8h x2d; consider continuing 600mg q8h ongoing for relapse^Citation58
Baclofen	Baclofen 10mg q8h x72h (adjunctive)^Citation93
Barbiturates	Phenobarbital 10mg/kg IV x one dose^Citation52 Phenobarbital 260mg IV x one plus 130mg IV x one 48h later “at discretion of treating physician”^Citation50

Abbreviations: CIWA, Clinical Institute Withdrawal Assessment; IV, intravenous; po, per os; prn, pro re nata.

Table 3 Level of Care for Alcohol Detoxification After Emergent Treatment

ASAM Criteria Level of Withdrawal Management	Severity of Withdrawal	Patient Needs	Disposition from Emergency Department
Ambulatory withdrawal management	Mild	-Requires less-than-daily outpatient supervision. -Able to follow return precautions. -Likely to adhere to withdrawal management. -Likely to continue AUD treatment.	Home
Ambulatory withdrawal management with on-site monitoring	Moderate	-Withdrawal management support and supervision needed during the day. -Has supportive living environment. -Likely to adhere to withdrawal management.	Home with family/outpatient support
Residential withdrawal management	Moderate	-24 hr support needed to adhere to withdrawal management. -Support important to increase likelihood of continuing treatment for AUD.	Residential detoxification program with clinical monitoring
Medically monitored inpatient withdrawal management	Severe	-24 hr nursing care with physician support as needed. -Unlikely to adhere to withdrawal management without medical monitoring.	-Residential detoxification program with 24 hr clinical monitoring and nursing care. -Consider inpatient medical floor admission.
Medically managed inpatient withdrawal management	Severe, unstable	-Requires 24 hr nursing care with daily physician visits to manage and modify withdrawal.	Inpatient medical floor
		-History of severe withdrawals, co-morbid medical condition requiring management, pregnancy.	Inpatient medical floor
		-Suicidal or homicidal ideation, co-morbid psychiatric condition requiring active management	Inpatient psychiatric unit
		-Older patients, active delirium tremens, severe agitation requiring sedation for safety.	Intensive care unit

Notes: Data from Simpson et al¹⁵ and Mee-Lee et al.⁸⁶

Abbreviations: ASAM, American Society of Addiction Medicine; AUD, alcohol use disorder.

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