Alcohol and benzodiazepine withdrawal (emergency department recognition and management)

Meet the patient

A 52-year-old man is brought to the emergency department 30 hours after his last drink. He is tremulous, diaphoretic and agitated, heart rate 128, blood pressure 178 over 104, temperature 38.1. He reports vivid visual hallucinations but is oriented to person and place. His bedside glucose is 4.2. The CIWA-Ar is 23.[1]

The two questions that decide his next hour are the two that decide every withdrawal case: how severe is the unopposed excitatory state? (the CIWA-Ar answers, and 23 is severe) and have I excluded the killers that mimic withdrawal? (sepsis, hyponatraemia, hypoglycaemia, hepatic encephalopathy, Wernicke, an intracranial bleed). Hold those two and the whole ladder slots into place.[1][6]

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