Severe alcohol withdrawal — CIWA-Ar, benzodiazepines and thiamine-first

This is severe alcohol withdrawal (likely CIWA-Ar in the moderate–severe range) with autonomic hyperactivity, tremor and hallucinations, plus concurrent hypoglycaemia. Agitation in the alcoholic is a diagnosis of informed exclusion — also consider sepsis, hyponatraemia, Wernicke encephalopathy, intracranial bleed after the fall, and hepatic encephalopathy.^[1][6]

Immediate priorities

• ABCDE; calm environment; IV access; full panel (electrolytes including Mg, glucose, LFTs, coag, CK, lactate, ECG).
• Thiamine 100 mg IV first, then correct glucose with IV dextrose — glucose metabolism consumes thiamine pyrophosphate; dextrose-first in a depleted host can precipitate Wernicke encephalopathy.^[5]
• Score with CIWA-Ar (10-item scale); treat when the score exceeds threshold with symptom-triggered benzodiazepine; severe scores with instability or seizure need parenteral benzodiazepines and HDU-level monitoring.^[1]

Pharmacotherapy

• First-line: long-acting benzodiazepines (Mayo-Smith meta-analysis).^[2]
• IV diazepam repeated until calm (symptom-triggered), or oral chlordiazepoxide if milder and oral route safe.
• Prefer symptom-triggered over fixed schedules — lower total dose and shorter stay.
• Hepatic failure: use lorazepam or oxazepam.
• Do not start an antiepileptic solely for an alcohol-withdrawal seizure once adequate benzodiazepine loading is achieved.
• If this were pure benzodiazepine withdrawal: reinstate a long-acting taper; flumazenil is contraindicated.

Escalate to HDU/ICU for delirium tremens, refractory agitation, or high-dose frequent boluses.^[6]