Alcohol withdrawal and delirium tremens

Also known as Alcohol withdrawal syndrome (AWS) · Delirium tremens (DTs) · Wernicke encephalopathy · CIWA-Ar scoring · Symptom-triggered therapy · PAWSS (Prediction of Alcohol Withdrawal Severity Scale) · Kindling phenomenon

Alcohol withdrawal symptoms typically begin 6-24 h after cessation/reduction of alcohol intake. Stages: minor withdrawal (tremor, anxiety, insomnia), seizures (12-48 h after last intake, in up to 15% of patients), hallucinosis (12-24 h, in 2-8%), delirium tremens (typically around 72 h; occurs in 3-5% of withdrawal patients — confusion, agitation, autonomic hyperactivity; untreated mortality can be as high as 50%). Pathophysiology: chronic ethanol down-regulates inhibitory GABA receptors and up-regulates excitatory NMDA receptors; abrupt cessation produces CNS hyperexcitability — the basis of seizures, hallucinosis and DTs. Management: benzodiazepines are the gold standard — symptom-triggered (scale-guided) dosing is favoured over fixed tapering; give thiamine before/with glucose; add phenobarbital (10-15 mg/kg IV weight-based loading) when benzodiazepines are insufficient; dexmedetomidine only as an adjunct for sympathetic overactivity.

medium18 referencesUpdated 26 July 202618 min readVerification in progress

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The one-line answer

Alcohol withdrawal is a hyper-excitable brain unmasked — chronic ethanol down-regulated inhibitory GABA receptors and up-regulated excitatory NMDA receptors, and when the alcohol stops the excitation runs wild. The spectrum climbs across hours: minor symptoms (tremor, anxiety, insomnia) begin within hours of the last drink, hallucinations at 12 to 24 hours (2-8% of patients), seizures at 12 to 48 hours (up to 15%), and delirium tremens around 72 hours (3-5% of patients) with confusion, autonomic storm, and untreated mortality as high as 50%. Treat with symptom-triggered benzodiazepines (scale-guided dosing favoured over fixed tapering), give thiamine before or with glucose, replete magnesium and folate, and reach for phenobarbital (10-15 mg/kg IV) when benzodiazepines fail. The mantra: benzos first, thiamine before glucose, never phenytoin for a withdrawal seizure.

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Timeline and stages

Alcohol withdrawal timeline (click each)

Seizures

Mortality Low-moderate

Generalised tonic-clonic seizures, typically 12-48 h after the last drink; occur in up to 15% of withdrawing patients. Benzodiazepines are the treatment of choice; anticonvulsants (carbamazepine, gabapentin) do not prevent seizures; phenytoin is an adjunct only for complications, not routine therapy.

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The four stages of alcohol withdrawal — side by side

Stage	Onset (after last drink)	Hallmark	Sensorium	Frequency	Disposition
Minor withdrawal	6-24 h (often within 8 h)	Tremor, anxiety, insomnia, nausea, sweating, tachycardia, hypertension	Clear	Most withdrawals	Ward/outpatient; benzodiazepine (fixed or symptom-triggered)
Withdrawal seizures	12-48 h	Generalised tonic-clonic	Brief post-ictal only	Up to 15% of patients	Observe; benzodiazepines are treatment of choice
Alcoholic hallucinosis	12-24 h	Visual typically more than auditory hallucinations	Clear — patient oriented	2-8% of patients	Ward/HDU; benzodiazepine
Delirium tremens (DTs)	~72 h	Confusion + agitation + autonomic storm + hallucinations	Altered — disoriented	3-5% of patients	ICU — high-dose IV benzodiazepine ± intubation; untreated mortality up to 50%