Alcohol and benzodiazepine withdrawal (emergency department recognition and management)

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Red flags

• Thiamine 100 mg intravenously BEFORE any glucose — giving dextrose to a thiamine-depleted alcoholic precipitates Wernicke encephalopathy; if hypoglycaemic, give thiamine first then the dextrose
• Delirium tremens (clouding of consciousness, severe autonomic hyperactivity, fever, hallucinations) is an ICU-level emergency with a measurable mortality — escalate to high-dependency care and intravenous diazepam or lorazepam
• An alcohol withdrawal seizure is treated with a long-acting benzodiazepine, NOT an antiepileptic — the mechanism is glutamatergic, and the recurrent-seizure risk is abolished by adequate benzodiazepine loading
• Flumazenil is contraindicated in the benzodiazepine-dependent patient — it precipitates severe withdrawal seizures that are refractory to treatment; manage benzo withdrawal by reinstating a long-acting agent as a taper
• Agitation in the alcoholic is a diagnosis of informed exclusion — actively exclude and treat sepsis, hyponatraemia, hypoglycaemia, hepatic encephalopathy, Wernicke and intracranial bleed before attributing the picture to withdrawal alone
• In hepatic failure use lorazepam or oxazepam (no active metabolites); chlordiazepoxide and diazepam accumulate and over-sedate