Alcohol withdrawal and delirium tremens

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Target exams

Red flags

• Delirium tremens — fluctuating consciousness, severe autonomic hyperactivity, hallucinations; medical emergency needing adequate benzodiazepines and often ICU
• Alcohol withdrawal seizure (typically 12–48 h after last drink) — treat withdrawal physiology; exclude alternative causes when atypical
• Prior DT or withdrawal seizure — default to inpatient detox; ambulatory cold-turkey is unsafe
• Suspected Wernicke encephalopathy (Caine: any two of malnutrition, oculomotor abnormality, cerebellar dysfunction, altered mental state) — high-dose parenteral thiamine now
• Unassessable patient scored with CIWA-Ar alone — do not withhold benzos for false-low scores
• Significant liver disease on long-acting diazepam loading — prefer lorazepam (or oxazepam) to avoid accumulation
• Dual alcohol–benzodiazepine dependence — expect prolonged severe withdrawal; do not stop GABA cover abruptly