Recommendations
Urgent
Identify any patient with features of severe alcohol withdrawal early. These patients need urgent treatment.
Involve senior support and consider referring the patient to critical care. Always give intravenous or high-dose benzodiazepines in a critical care environment.
In any patient who is alcohol-dependent and has stopped or reduced their alcohol intake within hours or days of presentation, look for at least one of:[1][2][3]
Alcohol withdrawal delirium (also known as delirium tremens)
This is a medical emergency.
Assess for hallucinations, delusions, profound confusion and delirium, coarse tremor, or features of clinical instability that start 48 to 72 hours after the patient’s last alcoholic drink.[1][2][3][7]
Give oral lorazepam or diazepam as first line if tolerated. Switch to intravenous lorazepam if symptoms persist. Add an antipsychotic if the patient fails to improve despite adequate treatment with intravenous lorazepam.
The patient may require phenobarbital and rapid tranquilisation for persistent symptoms.
A high or worsening CIWA-Ar ( Clinical Institute Withdrawal Assessment of Alcohol, revised Opens in new window) or GMAWS ( Glasgow Modified Alcohol Withdrawal Scale Opens in new window) score
Failure to improve after two doses of a benzodiazepine
Alcohol withdrawal seizure[1][2][3]
Look for generalised tonic-clonic seizures.
Ensure a patent airway immediately.
Give intravenous lorazepam to control seizures.
Deranged temperature or deranged blood pressure or deranged blood glucose, alongside any feature of alcohol withdrawal.
Rule out other causes such as head injury or central nervous system infection.
Assess mental capacity early.
Consult local protocols and involve senior support in patients who lack capacity.
These patients are at high risk of absconding and causing harm to themselves.
Key Recommendations
Suspect acute or imminent alcohol withdrawal in any patient who is alcohol-dependent and has stopped or reduced their alcohol intake within hours or days of presentation.[1][2][3]
Clinical presentation
Symptoms vary according to severity. Common symptoms include [1][2][3][7][41]
Anxiety
Nausea and vomiting
Autonomic dysfunction
Tremor
Tachycardia
Sweating
Palpitations
Insomnia.
Screen for alcohol-use disorder and alcohol dependence
Use a formal screening tool, such as AUDIT-C ( Alcohol Use Disorders Identification Test - Consumption Opens in new window), FAST ( Fast Alcohol Screening Test Opens in new window), or PAT ( Paddington Alcohol Test 2011 Opens in new window), to screen patients for alcohol-use disorder. The full AUDIT ( Alcohol Use Disorders Identification Test Opens in new window) may also be used, but it takes longer to perform and therefore may not be suitable in an acute hospital setting.[2]
Identify patients at risk of alcohol withdrawal by assessing the level of alcohol dependence of patients who have tested positive for alcohol-use disorder.[2]
Use a formal screening tool such as SAD-Q ( Severity of Alcohol Dependence Questionnaire Opens in new window) or CAGE.
If using CAGE, ask four questions:[42]
C: Have you felt the need to cut down on your drinking?
A: Have you ever felt annoyed by someone criticising your drinking?
G: Have you ever felt bad or guilty about your drinking?
E: Have you ever had an eye-opener - a drink first thing in the morning to steady your nerves?
History
Ask about the subjective features of alcohol withdrawal. These include:
Anxiety
Nausea
Insomnia
Headache
Tactile, visual, and auditory disturbances
Blackouts, unexplained loss of consciousness, or seizures.
Assess orientation to time, person, and place.
Ask about other current substance misuse and other medical comorbidities, including a psychiatric and social history.[1]
Identify the reason for cessation or reduction of alcohol intake.
Ask about risk factors for hepatitis B, hepatitis C, and HIV infection.
These can co-exist with or complicate alcohol withdrawal.
Physical examination
Assess for signs of alcohol withdrawal including a tremor.[1][2][3]
Look for signs of Wernicke’s encephalopathy. These include nystagmus, ataxia, and confusion. See our topic Wernicke’s encephalopathy.
Look for signs of head injury. See our topic Assessment of traumatic brain injury, acute.
Investigations
Alcohol withdrawal is a clinical diagnosis. However, use test results to help add weight to a suspicion of alcohol-use disorder.[1][2][3]
Always order:
Venous blood gas
Blood glucose
Full blood count
Urea and electrolytes including magnesium and phosphate
Liver function tests including gamma-glutamyl transpeptidase (GGT)
Bone profile
Coagulation studies.
Always interpret test results in the context of the patient’s clinical history and other findings.
It is important to rule out significant concurrent physical illness that may have led to a reduction in alcohol intake.[2]
Consider additional tests based on individual presentations and to rule out other causes.
Suspect acute or imminent alcohol withdrawal in any patient who is alcohol-dependent and has stopped or reduced their alcohol intake within hours or days of presentation.[1][2][3]
Ask when the patient’s last drink was to determine the onset of timing of their symptoms.
Mild to moderate symptoms tend to start 6 to 12 hours after the patient’s last alcoholic drink and peak between 24 and 36 hours.[2][4][5][7]
Alcohol withdrawal delirium tends to start 48 to 72 hours after the patient’s last alcoholic drink and peaks at 5 days.[1][2][3][7]
Alcohol withdrawal seizures tend to occur in the first 12 to 24 hours.[10]
Be aware that patients may present in different ways, including:[43]
In acute withdrawal
After presenting for another reason
Alcohol-use disorders can complicate the assessment and treatment of other conditions
Wanting to stop drinking, therefore putting them at risk of acute withdrawal.
Practical tip
People may present with subtle signs of alcohol dependence, including:
Frequent falls or other accidents
Smelling of alcohol at inappropriate times (e.g., in the middle of the day).
Take time to ask about their alcohol use. Use a sensitive approach and avoid patronising or judgemental language. Bear in mind that the patient may be defensive about your questioning or fear being labelled as an ‘alcoholic’.
Seek senior advice if you are unsure about the diagnosis.
A premature diagnosis of alcohol withdrawal can lead to inappropriate use of sedatives, which can further delay accurate diagnosis.[44]
It is important to rule out other causes that can mimic or co-exist with alcohol withdrawal as these can be easily missed:
Use a validated scoring system, such as CIWA-Ar ( Clinical Institute Withdrawal Assessment of Alcohol, revised Opens in new window) or GMAWS ( Glasgow Modified Alcohol Withdrawal Scale Opens in new window) with your clinical judgement to assess all patients with alcohol withdrawal, to gauge severity and guide management.[1][2][3]
Check local protocols for recommendations on which scale to use and cut-off values for mild, moderate, and severe withdrawal. GMAWS is an alternative to CIWA-Ar for use in an acute hospital setting.[33]
Assign a score to each item, based on your observations and the patient’s answers to structured questioning.
Speak slowly and clearly; reword questions if needed.
Add up the number of points to reach a total.
Use the total CIWA-Ar or GMAWS score to:[2][3]
Determine which patients need drug treatment
In general, patients with a CIWA-Ar score <10 or GMAWS <2 do not require drug treatment. However, they may require a period of monitoring and supportive treatment[3]
Decide whether a patient is suitable for outpatient management
Monitor patients during treatment.
Regardless of severity score, a patient having seizures or alcohol withdrawal delirium during the alcohol withdrawal period indicates severe withdrawal.[46]
Practical tip
Be careful not to underestimate or miscalculate the CIWA-Ar score. The patient may develop worsening withdrawal symptoms if they are not treated according to the severity of their symptoms.
This is a common pitfall when assessing people who are sedated, are acutely agitated, or have language barriers. It may be difficult to use CIWA-Ar for these people as it relies on subjective reporting by the patient (e.g., for anxiety, nausea, and headache). Therefore, use your clinical judgement instead of CIWA-Ar score in these patients.
Evidence: Validation of CIWA-Ar
CIWA-Ar has been validated in many clinical settings with some exceptions such as the emergency department.
CIWA-Ar has been shown to be effective for monitoring and determining future treatments. Evidence has shown that using CIWA-Ar to determine dose and frequency of a benzodiazepine reduces the overall amount of benzodiazepine given and the total treatment time [47][48]
CIWA-Ar has also been validated when translated into other languages such as German.[49]
One study showed that the original CIWA score (an earlier iteration of the CIWA-Ar score with 15 items rather than 10) had good inter-rater validity by comparing scores rated by nurses with a 3-point global rating of severity made by a physician on initial assessment of the patient.[50][51]
However CIWA-Ar has not been validated for use in certain settings such as the emergency department.[51]
Severe withdrawal symptoms
Identify patients with features of severe alcohol withdrawal early. Involve senior support and consider referring the patient to critical care.
In any patient who is alcohol-dependent and has stopped or reduced their alcohol intake within hours or days of presentation, look for at least one of:[1][2][3][33]
A high or worsening CIWA-Ar ( Clinical Institute Withdrawal Assessment of Alcohol, revised Opens in new window) or GMAWS ( Glasgow Modified Alcohol Withdrawal Scale Opens in new window) score
Failure to improve after two doses of a benzodiazepine
Deranged temperature or deranged blood pressure or deranged blood glucose, alongside any feature of alcohol withdrawal.
Alcohol withdrawal delirium
Involve early senior support and consider referring the patient to critical care if you suspect alcohol withdrawal delirium (also known as delirium tremens). This is a medical emergency and is present in around 5% of patients with alcohol withdrawal.[9] These patients require urgent treatment (see the Management Recommendations section).
Give oral lorazepam or diazepam if tolerated and switch to intravenous lorazepam if symptoms persist.
Always give intravenous or high-dose benzodiazepines in a critical care environment.
Benzodiazepines can cause respiratory depression, particularly at higher doses or when given parenterally; therefore, facilities for managing respiratory depression with mechanical ventilation must be immediately available.
Consider adding an antipsychotic if an adequate dose of a benzodiazepine has been given.
The patient may require rapid tranquilisation.
Early detection of alcohol withdrawal and prompt initiation of treatment is key to preventing the onset of alcohol withdrawal delirium.
Alcohol withdrawal delirium symptoms are rapid in onset and difficult to control. They tend to appear 48 to 72 hours after the patient’s last alcoholic drink and may include:
Profound confusion/delirium[9][10]
This is fluctuating in nature and the patient may be disorientated to time, person, and place.
There is also clouding of consciousness.
Ask the patient to estimate how long your consultation has lasted.[52] Mild impairment of consciousness can occur in alcohol withdrawal delirium and can cause difficulty in estimating the passage of time.
Always consider Wernicke’s encephalopathy in any confused patient with alcohol dependence. This is a neurological emergency. See our topic Wernicke’s encephalopathy.
Visual, auditory, and tactile hallucinations; characteristically frightening delusions[10]
Coarse tremor[10]
Features of clinical instability, which include tachycardia, fever, ketoacidosis, and circulatory collapse.[10]
Practical tip
Be aware of alcohol-induced psychotic disorder with hallucinations (previously known as alcoholic hallucinosis), a rare condition in chronic heavy drinkers that can be difficult to differentiate from withdrawal-induced psychosis. See the Differentials section for more details.
More info: Alcohol withdrawal delirium
Alcohol withdrawal delirium is fatal in 15% to 20% of patients if untreated.[34][35] Appropriate early management reduces mortality to around 1%.[9] Patients most at risk of death with alcohol withdrawal delirium are those with a high fever (>39.9°C), tachycardia, dehydration and an associated illness (e.g., pneumonia or pancreatitis), or general debility, or where the diagnosis is delayed.[6]
More info: Wernicke’s encephalopathy
Wernicke’s encephalopathy results from thiamine deficiency and has varied neurocognitive manifestations, which typically involve mental status changes and gait and oculomotor dysfunction.[54] It is present in 12.5% of patients with alcohol dependence.[55]
See our topic Wernicke’s encephalopathy.
Alcohol withdrawal seizures
Look for generalised tonic-clonic seizures. These patients require urgent treatment (see the Management Recommendations section).
Ensure a patent airway immediately.
Give intravenous lorazepam to control seizures. Always give intravenous benzodiazepines in a critical care environment.
Benzodiazepines can cause respiratory depression, particularly when given parenterally; therefore, facilities for managing respiratory depression with mechanical ventilation must be immediately available.
See our topic Generalised seizures for more information.
Rule out causes other than alcohol withdrawal, especially if:[45]
Seizures are focal
There is no definite history of recent abstinence from drinking
Seizures occur more than 48 hours after the patient’s last drink (alcohol withdrawal seizures normally occur in the first 12 to 48 hours)[10]
The patient has a history of fever or trauma.
Check capillary blood glucose in all patients with seizures.[56] Other common causes of seizures include significant head injury and central nervous system infection.[36][57]
Request a CT head in any patient who has had a seizure.[37][38] Consider using electroencephalography to help confirm the seizure has ended, particularly if there is suspicion of ongoing subtle seizures in an unresponsive or anaesthetised patient.[58]
Practical tip
Seizures may be the first manifestation of alcohol withdrawal in some people.[3]
They develop due to changes in alcohol concentration and therefore may occur before the blood alcohol level has fallen to zero.[6]
Alcohol withdrawal is one of the most common causes of status epilepticus.[3] Several other legal and illegal pharmacological agents may induce seizures, due to either drug withdrawal (e.g., benzodiazepines) or a direct neurotoxic effect (e.g., antipsychotics, antidepressants, or stimulants). These may complicate the clinical picture and should be considered in the diagnosis of alcohol-related seizures.
Liver dysfunction and hepatic encephalopathy may also present with seizures.
Moderate or mild withdrawal symptoms
Not all patients with symptoms of alcohol withdrawal will need acute pharmacological treatment. You may be able to use supportive care to manage patients with mild to moderate alcohol withdrawal symptoms.[3]
Moderate withdrawal symptoms include:
Restlessness
Coarse tremor
May be present in moderate alcohol withdrawal but is usually a sign of more severe alcohol withdrawal or alcohol withdrawal delirium[10]
Worsening minor symptoms.
Mild symptoms include:
Insomnia and fatigue
Tremor
Mild anxiety/feeling nervous
Mild restlessness
Nausea and vomiting
Headache
Excessive sweating
Palpitations
Anorexia
Depression
Craving for alcohol.
Practical tip
Look for a tremor by asking the patient to extend their arms and spread their fingers apart.[53]
Mild tremor: may not be seen; can be felt fingertip to fingertip.
Moderate tremor: can be seen with arms extended.
Severe tremor: can be seen even without arms extended.
Be aware that some patients with mild or moderate withdrawal symptoms are at higher risk of developing severe withdrawal. Risk factors include:[1][12][32][59][60]
Fever
High levels of anxiety
Tachycardia
Hypoglycaemia
Poor physical health
Sweating
Hypocalcaemia
Other psychiatric disorders
Concomitant use of other psychotropic drugs
Previous history of severe withdrawal, seizures, and/or alcohol withdrawal delirium
Hypokalaemia (with respiratory alkalosis)
High alcohol intake (>15 units per day in a person of average build).
Mental capacity
Assess mental capacity early. Involve senior support when managing patients who lack capacity.
You must be certain that the patient has capacity to make decisions about their treatment, including remaining in hospital.
In hospitals and care homes in England and Wales, use the Deprivation of Liberty Safeguards (DoLS) if a patient lacks capacity to make these decisions.[61] SCIE: Deprivation of Liberty Safeguards (DoLS) at a glance Opens in new window
Practical tip
Patients who are withdrawing from alcohol are at high risk of absconding.[62][63]
This is why it is important to assess their mental capacity soon after presentation.
In practice, patients with capacity can often be persuaded to stay in hospital with a gentle approach in a calm and supportive environment.
Carefully document your assessment of a patient’s mental capacity; include thorough details of the decisions made at each stage.
Symptoms
Ask specifically about subjective symptoms of alcohol withdrawal. These include:
Anxiety
Nausea
Insomnia
Headache
Tactile, visual, and auditory disturbances
A history of blackouts, unexplained loss of consciousness, or seizures.
Determine whether the patient is orientated to time, person, and place.
Screening tools
Use validated screening tools to: (i) identify any patient with alcohol-use disorder and (ii) assess the level of alcohol dependence in those who have tested positive for alcohol misuse.
Screen the patient for alcohol-use disorder using a formal assessment tool such as AUDIT-C, FAST, PAT, or AUDIT.[2] Decide which to use based on local protocols, the setting of care, and your preference.
AUDIT-C ( Alcohol Use Disorders Identification Test - Consumption Opens in new window)[2]
A total score of ≥5 is a positive screen.
FAST ( Fast Alcohol Screening Test Opens in new window)
Conceived for use in emergency departments but can be used in a wide variety of settings.[3]
PAT ( Paddington Alcohol Test 2011 Opens in new window)
Takes less than a minute to perform and useful in busy clinical settings.[64]
AUDIT ( Alcohol Use Disorders Identification Test Opens in new window)
The full version of AUDIT; takes longer to perform than the other screening tools and therefore may not be suitable in an acute hospital setting.[2]
Practical tip
It is important to calculate units of alcohol formally when using a screening tool as the increasing strength of alcoholic drinks and the larger glass sizes served in bars mean that people often drink more alcohol than they realise.[10]
Calculate units of alcohol as follows:[10]
Number of units of alcohol = % ABV (alcohol by volume) x Volume (Litres)
Online calculators can also be useful. Alcohol Change UK: Unit calculator Opens in new window
The risk of alcohol withdrawal is not directly related to intake. Some people who drink a lot of alcohol do not have withdrawal symptoms if they stop drinking.[60]
Evidence: Validity of formal assessment tools for alcohol-use disorder
Evidence has shown that commonly used formal assessment tools are effective at detecting alcohol-use disorder.
Abbreviated versions of AUDIT, such as AUDIT-C and FAST, were developed for use in acute settings where the full AUDIT would take too long to perform. These compare favourably with the full screening tool.
In a comparison of AUDIT with AUDIT-C and FAST in primary care:[65]
AUDIT-C was more sensitive than AUDIT and therefore a reliable test that could be used in place of the full version
FAST had a lower sensitivity than AUDIT
Therefore, AUDIT-C was recommended over FAST in primary care.
PAT can be administered in about one fifth of the time taken to administer AUDIT and therefore may be useful in busy clinical settings. In a sample of 47 clinicians assessing people presenting to an emergency department in the UK, it took:[64]
20 seconds to complete PAT (SD = 9.53)
1 minute 13 seconds to complete AUDIT (SD = 27.6).
Evidence: Screening for alcohol-use disorder is performed poorly worldwide
Studies in Australia, the UK, the US, and Finland have demonstrated that clinicians infrequently screen for alcohol-use disorder; in at least one third to half of cases where the diagnosis is known, they fail to address the problem.[66][67][68]
Other studies have reported on the quality of history taking in relation to alcohol use and suggested that poor alcohol history taking is prevalent in many clinical settings.[69][70][71] Some data show that no alcohol history of any sort was documented in the medical notes of more than 30% to 40% of acute general medical hospital admissions.[72][73]
It has been shown that screening and brief intervention programmes have beneficial long-term effects in cases of alcohol-use disorder, and hospital-based substance use consultations are reported to improve engagement in alcohol rehabilitation and treatment outcomes.[74][75]
Identify patients who have tested positive for alcohol misuse and are at risk of alcohol withdrawal by assessing their level of alcohol dependence. AUDIT-C, FAST, PAT, and AUDIT only identify alcohol-use disorder and do not predict which patients are at risk of alcohol withdrawal. Decide which screening tool to use based on local protocols and your preference. Use either SAD-Q or the CAGE questionnaire.
SAD-Q Severity of Alcohol Dependence Questionnaire Opens in new window[32]
This can help guide drug doses for treatment as well as identifying those at risk of alcohol withdrawal delirium.
A chlordiazepoxide detoxification regimen is usually indicated for anyone who scores ≥16.
Ask four questions:[42]
C: Have you felt the need to cut down on your drinking?
A: Have you ever felt annoyed by someone criticising your drinking?
G: Have you ever felt bad or guilty about your drinking?
E: Have you ever had an eye-opener - a drink first thing in the morning to steady your nerves?
The test is considered positive if score ≥2.
This is a brief and effective test for lifetime alcohol abuse or dependence. It is commonly used in clinical practice.
However, it fails to detect binge drinking and is less sensitive in screening for mild to moderate alcohol withdrawal than other screening tools. It also does not distinguish between active and past problem drinking.[3][5][76]
Evidence: Use of CAGE
Studies have found that CAGE performs generally well in primary care settings but is less effective in certain populations (e.g., heavy drinkers).
Evidence: Use of SAD-Q
SAD-Q is considered a valid and reliable screening tool that has shown high test-retest reliability.
SAD-Q has showed good test-retest reliability and significant correlations with observer ratings of withdrawal severity and narrowing of the drinking repertoire (e.g., drinking only one brand or type of alcohol rather than a variety of drinks).[82][83]
This has been independently confirmed in a sample of 102 people with alcohol-use disorder.[84]
Take account of the amount of alcohol that the patient reports drinking prior to admission/assessment as well as the result of SAD-Q/CAGE screening.[3]
Ask about changes in drinking patterns, at least during the previous 5 days, as well as the time of the patient’s last drink.[3]
Practical tip
Consider other diagnoses if the patient has consumed alcohol in the last 6 hours as alcohol withdrawal is unlikely within this timeframe. However, it is important to remember that patients can experience withdrawal symptoms even if their blood alcohol level has not reached zero.
Ask about other current substance misuse as well as comorbidities, including a psychiatric and social history.[1]
Include a history of any injuries, especially head injury. Ask about:[36]
History of the injury – in particular, dangerous mechanisms (e.g., a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle, or a fall from a height of >1 metre or 5 stairs)
Vomiting
Retrograde amnesia.
Identify why the patient has stopped or reduced their alcohol intake. Concurrent medical illness could be a factor as could social reasons (e.g., lack of money).
Ask about risk factors for hepatitis B, hepatitis C, and HIV infection. These can co-exist with or complicate alcohol withdrawal.
Take a collateral history.
Ask a relative or friend about the patient’s alcohol intake whenever possible as patients may frequently underreport their own consumption.[3]
This may help the patient discuss their alcohol use more openly.
Ensure the relative/friend has access to support to cope with the impact that the patient’s alcohol use has on them. Most alcohol services now offer this. Carers Trust: Caring for someone with alcohol or substance misuse issues Opens in new window
Assess for signs of alcohol withdrawal, commonly [1][2][3][7][41]
Anxiety
Ranges from the patient appearing at ease, but being mildly nervous, to acute panic states
Nausea and vomiting
Confusion
Autonomic dysfunction
Tremor
Tachycardia
Sweating
Palpitations
Agitation.
Look for signs of Wernicke’s encephalopathy. These include nystagmus, ataxia, and confusion. See our topic Wernicke’s encephalopathy.
Look for signs of head injury.
Can mimic or complicate alcohol withdrawal and can cause seizures. Have a low threshold for investigating with a CT head.
In particular, assess for:[36]
Glasgow Coma Score (GCS) <13 on initial assessment in the emergency department [ Glasgow Coma Scale Opens in new window ]
GCS <15 at 2 hours after the injury on assessment in the emergency department
An open or depressed skull fracture
Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign)
Focal neurological deficit.
See our topic Assessment of traumatic brain injury, acute for more information.
Evidence: Head injury and alcohol-use disorder
Alcohol-related injuries, particularly head injuries, constitute a significant proportion of patients seen in the emergency department.
Alcohol-related head injuries are particularly seen among young men, and are a common cause of seizures.
As many as half of patients with significant head injury are under the influence of alcohol at the time of injury. Traumatic brain injuries (TBIs) frequently cause epileptic seizures. On the other hand, epileptic seizures are often caused by alcohol.[85]
Alcohol abuse and TBI frequently co-occur, and alcohol consumption is common both before and after injury.[85] As many as one half of all patients with TBI are intoxicated on admission, and TBI recurrence is more common among patients with alcohol abuse than among others.[86][87]
Alcohol-related injuries constitute a significant proportion of patients seen in the emergency department.
Two studies have specifically examined the contribution of alcohol to head injuries presenting to accident and emergency (A&E) departments in the UK.
The first reported that 43% of 204 patients with head injuries presenting to an A&E department over a 10 week period had alcohol in their urine.[88]
A second, much larger study reported the workload pattern related to head injuries on an acute surgical unit in a central London teaching hospital.[89] Over a 6 month period, 899 patients with head injuries were treated in the A&E department, of whom 156 were admitted. Of these, 51% of the adult admissions were intoxicated by alcohol, and alcohol was associated with a significantly increased length of stay.
An audit of 6114 patients with facial injuries presenting to 163 A&E departments in the UK during a week in 1997 reported that at least 22% were associated with alcohol consumption within 4 hours of the injury.[90]
A study from Edinburgh examining 369 consecutive A&E admissions to a male ‘acute’ orthopaedic ward reported that alcohol had contributed to the accident in 19% of cases according to clinical assessment.[91]
Assess for features of acute medical illness and chronic or decompensated liver disease due to alcohol-use disorder. Be aware that all these patients need admission.
Commonly associated acute illnesses include:
Pneumonia
Pancreatitis
Hepatitis
Gastritis (see More info: Management of gastritis below).
Features of chronic or decompensated liver disease tend to be late signs of liver disease and therefore may not be present in all patients. These patients should be managed by a specialist. These features include:
See our topics Alcoholic liver disease, Community-acquired pneumonia, Acute pancreatitis, and Gastritis for more detail.
More info: Management of gastritis
Gastritis secondary to heavy alcohol use is common in patients with alcohol withdrawal. It is important to recognise and treat this. Alleviating the unpleasant symptoms will help keep the patient calm and settled, therefore reducing the risk of them absconding.
Use a proton pump inhibitor (e.g., omeprazole) for treatment in the acute setting. If there is persistent hypomagnesaemia or hypokalaemia consider switching to an H2 receptor antagonist (e.g., ranitidine).[93][94]
Alcohol withdrawal is a clinical diagnosis. However, test results may add weight to a suspicion of alcohol-use disorder and can be used to rule out other causes.[1][2][3]
Always interpret test results in the context of the patient’s clinical history and other findings.
Do not test blood alcohol level using a breathalyser, unless you suspect that the patient is continuing to drink alcohol as an inpatient.
Do not use blood tests as general screening tools for alcohol misuse.
However, they may be used alongside a formal screening tool (such as AUDIT-C [ Alcohol Use Disorders Identification Test - Consumption Opens in new window], FAST [ Fast Alcohol Screening Test Opens in new window], PAT [ Paddington Alcohol Test 2011 Opens in new window], or AUDIT [ Alcohol Use Disorders Identification Test Opens in new window) to screen for alcohol misuse.
Blood tests are less sensitive than a formal screening tool. However, they can support a clinical suspicion of alcohol misuse if alcohol consumption history is unavailable or considered unreliable.[3] They can also be used to monitor the patient's adherence to an alcohol intervention programme.
Evidence: Urine drug screening in alcohol withdrawal
In the acute setting, urine drug screening has little benefit and is not commonly used.
A prospective analysis of 218 psychiatric patients in the emergency department compared self reporting of alcohol to urine drug screening. It showed that a drug and alcohol history was better than drug screening for detecting alcohol and cannabis use.[95]
A review of over 1400 patients showed that using a urine drug screen had no significant impact on how patients were managed in the emergency setting.[96]
Always order
Venous blood gas
May show:
Respiratory alkalosis in patients with alcohol withdrawal delirium due to significantly elevated cardiac indices, oxygen delivery, and oxygen consumption[97]
Hyperventilation and consequent respiratory alkalosis with alcohol withdrawal delirium may result in a significant decrease in cerebral blood flow[97]
Hypochloraemic metabolic acidosis with vomiting[98]
Metabolic acidosis with a high anion gap if alcohol ketoacidosis is present. This is a potential cause of alcohol withdrawal as well as a differential diagnosis.[99]
Blood glucose
Hypoglycaemia is common in patients with alcohol dependence or withdrawal and may be secondary to poor nutrition or heavy alcohol use.
Replace glucose orally if tolerated or intravenously if the patient has impaired consciousness. Consider intramuscular glucose if venous access is unavailable.
If you give glucose, give it at the same time or after thiamine. However, do not delay glucose for life-threatening hypoglycaemia while waiting for thiamine administration.
Some evidence suggests that prolonged glucose supplementation without the addition of thiamine can be a risk factor for the development of Wernicke's encephalopathy.[100][101][102]
Full blood count
Increased mean corpuscular volume is indicative of chronic alcohol-use disorder.[5]
May remain elevated 3 to 4 months after the patient stops drinking alcohol.
Not a specific test; can be elevated as a result of vitamin B12 or folate deficiency.
Thrombocytopenia in patients with alcohol-use disorder is caused by splenomegaly, folate deficiency, and, most frequently, a direct toxic effect of alcohol on production, survival time, and function of platelets.[103]
Generally benign; clinically significant haemorrhage is rare.[103]
Urea and electrolytes
Electrolyte deficiencies are common in people with chronic alcohol-use disorder.[104]
They can cause life-threatening cardiac arrhythmias; always perform an ECG on patients with electrolyte deficiencies.[105][106][107][108]
In those admitted to hospital with chronic alcohol-use disorder, plasma magnesium, potassium, and phosphorus concentrations may be normal or only slightly reduced on admission, only to decrease over several days. This is due to an inward cellular shift that unmasks decreased total-body stores.[104]
Hypomagnesaemia: occurs in almost one third of people with chronic alcohol-use disorder [104]
Practical tip
Hypocalcaemia and hypokalaemia will not resolve until adequate magnesium replacement is given.[109]
Hypokalaemia: seen in nearly 50% of hospitalised patients with chronic alcohol-use disorder [104]
Results from inadequate intake and gastrointestinal losses due to diarrhoea. Urinary losses also contribute.
Hypophosphataemia (refeeding syndrome): develops in up to 50% in patients hospitalised for problems related to chronic alcohol overuse [104]
Liver function tests
Liver enzymes (aspartate aminotransferase [AST], alanine aminotransferase [ALT], and gamma-glutamyl transpeptidase [GGT]) may be elevated.[110]
ALT: almost always elevated, and normally higher than AST, in patients with alcoholic liver disease. The classic ratio of AST:ALT >2 is seen in about 70% of patients.[110]
GGT: may be increased with heavy alcohol consumption [111]
Usually returns to normal levels within 2 to 3 weeks after the patient stops drinking alcohol if there is no chronic liver damage [111]
GGT greater than 10 times the upper limit of normal is commonly associated with excessive drinking.[112] Smaller elevations of GGT (e.g., 2-3 times the upper limit of normal) tend to be caused by other conditions including non-alcoholic fatty liver disease.[113]
Bone profile
Use to detect:
Hypocalcaemia[104]
Secondary to hypomagnesaemia suppressing parathyroid hormone
Low vitamin D[104]
Risk factors include:
Poor dietary intake of vitamin D
Lack of exposure to sunlight
Direct effects of alcohol on vitamin D metabolism
Decreased absorption in patients with alcohol-related steatorrhoea.
Coagulation studies
International normalised ratio (INR) and prothrombin time (PT) may be prolonged in chronic liver disease.[114]
They correlate well with the severity of liver disease but are not predictive of bleeding risk.
Activated partial thromboplastin time (aPTT) does not usually reflect liver dysfunction; it is typically normal or nearly normal in liver disease.[114]
Consider requesting
Blood cultures
Request in patients who are febrile to look for evidence of infection.[115]
Computed tomography (CT) head
Request in patients with any one of:
Use the Glasgow Coma Scale (GCS) to assess conscious level [ Glasgow Coma Scale Opens in new window ]
Suspected head injury plus one of the following:[36]
GCS <13 on initial assessment
GCS <15 at 2 hours after the injury on assessment
Suspected open or depressed skull fracture
Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ears or nose, Battle’s sign)
Post-traumatic seizure
Focal neurological deficit
>1 episode of vomiting.
Practical tip
Always suspect head injury in patients who are withdrawing from alcohol; have a low threshold for requesting a CT head. Alcohol intoxication is an independent risk factor for a positive finding on CT head following head injury [116] Patients who drink heavily are more likely to bleed after a head injury due to deranged clotting and thrombocytopenia.
Chest x-ray
Consider if there are signs of respiratory distress.
Co-existing pneumonia is common in patients with alcohol withdrawal.[117]
There is also the possibility of aspiration, especially in people with reduced consciousness or those who have had seizures.[118]
ECG
Perform in patients with tachycardia to look for arrhythmias.
These include atrial fibrillation and ventricular tachyarrhythmias.[119]
Amylase and lipase
Measure if there is abdominal pain, diarrhoea, or nausea and vomiting.[120][121]
Elevated levels may indicate acute pancreatitis which is a complication of heavy alcohol use.[120] See our topic Acute pancreatitis.
Ammonia
Consider in all patients with an altered level of consciousness and signs of liver disease.
Elevation may indicate liver failure.[122]
Practical tip
Check local protocols before taking an ammonia sample as guidelines vary. The sample may need to be sent on ice and there may be a time limit (from taking the sample to testing) to adhere to.
Lumbar puncture
Perform a lumbar puncture if you suspect subarachnoid haemorrhage (SAH) and the initial CT head is normal or if you suspect central nervous system (CNS) infection.[57][123]
Consider CNS infection or SAH if symptoms of confusion are worsening or failing to improve despite treatment for alcohol withdrawal, especially if the patient has a headache, fever, or neck stiffness.
Treat empirically if there is diagnostic uncertainty before waiting for lumbar puncture results.[124]
Electroencephalography (EEG)
Perform in all patients with first presentation of an alcohol withdrawal seizure or when there is a new seizure pattern in patients with a known history of alcohol-related seizures (e.g., focal seizures or status epilepticus).[58]
Use EEG to help confirm the seizure has ended, particularly if you suspect ongoing subtle seizures in an unresponsive or anaesthetised patient.[58]
The incidence of EEG abnormalities is lower with alcohol withdrawal seizures than other causes of seizures.[3]
Do not perform an EEG if the patient has had previous comprehensive investigation of their seizures and the pattern of current seizures is consistent with past events.[58]
Practical tip
Access to EEG is limited; it is not commonly used outside of the intensive care setting.
Evidence: Use of EEG in alcohol withdrawal seizures
There is limited evidence to support either the use of EEG in alcohol withdrawal seizures or the notion that EEG monitoring independently improves outcome in convulsive status epilepticus (SE).
Blood-borne virus screen
Order if you suspect hepatitis B, hepatitis C, or HIV infection.
Take a comprehensive history and use this, alongside examination findings, to guide whether to admit the patient to hospital.
Consider admission to hospital in:[1][32]
Young people (under 16 years)
Those at high risk of developing alcohol withdrawal seizures or alcohol withdrawal delirium. These patients typically have at least one of:
A score >30 on SAD-Q
Alcohol intake >30 units of alcohol per day
Signs and symptoms of autonomic overactivity (e.g., tremor, tachycardia sweating, or palpitations)
Signs of intoxication.
Evidence: Factors that increase the risk of severe withdrawal symptoms
It has been proposed that an increased number of medically assisted withdrawals is a risk factor for the development of severe withdrawal symptoms.
Evidence shows that patients with a history of previous assisted withdrawals are significantly more likely to develop severe withdrawal symptoms.
One study showed that severe withdrawal symptoms (defined as a requirement for ≥600 mg of total, cumulative chlordiazepoxide) was significantly associated with participation in two or more prior alcohol treatment programmes.[127]
It has also been demonstrated that ≥2 previous assisted alcohol withdrawals is associated with a slower rate of decline on the CIWA-Ar on days 0 to 4 of the ongoing withdrawal.[128]
Studies report that patients with a history of previous detoxifications or withdrawals (particularly in the last 3 years) are significantly more likely to experience a seizure.[29][129][130]
One study looked at the risk of developing severe withdrawal symptoms after assessment in the emergency department. It showed that a history of withdrawal seizures independently contributed 6.8% to the risk of developing alcohol withdrawal delirium (although this study uses the term 'delirium tremens' instead of 'alcohol withdrawal delirium') as part of the ongoing withdrawal. It also identified that a history of alcohol withdrawal delirium contributed 6% to the risk of developing alcohol withdrawal delirium . Signs of overactivity of the autonomic nervous system accompanied by an alcohol concentration of >100 mg/dL of body fluid was also significantly associated with the development of alcohol withdrawal delirium.[131]
Other factors that increase the risk of severe withdrawal include:[127][132][133]
Increased blood alcohol level on admission
One study reported a blood alcohol level >43 mmol/L (200 mg/dL) as a significant predictor[132]
Increased number of days since last alcohol intake.
A history of alcohol withdrawal delirium.
If considering discharge (without admission) advise the patient to continue drinking alcohol. Stopping abruptly may lead to severe withdrawal.
If possible, the patient should gradually reduce their intake over several weeks/months.
It is common practice to advise them to decrease their level of drinking by not more than 25% every 2 weeks.
Have a lower threshold when considering admission to hospital of vulnerable people who are in acute alcohol withdrawal. These include people who:[1][32]
Are frail
Have cognitive impairment or multiple comorbidities, including poorly controlled chronic medical conditions and serious psychiatric conditions such as suicidal ideation and psychosis
Lack social support
Have learning difficulties
Are aged 16 or 17 years.
Practical tip
Pay attention to why the patient has stopped drinking. They may have run out of money or feel too unwell (owing to concomitant illness) to drink alcohol and are therefore at risk of developing worsening symptoms if they aren’t admitted for medically assisted withdrawal.
Never advise a patient who is being discharged to suddenly stop or reduce their drinking as this could precipitate severe symptoms. Signpost to outpatient services where controlled withdrawal can be organised.[1] Check local protocols for what is recommended and available in your area.
Many patients who are alcohol-dependent manage their withdrawal symptoms every day with continued alcohol consumption. It is often appropriate to continue this until the patient can be assessed formally by addiction services who will help determine the best treatment for the individual patient.[2]
Unnecessary inpatient detoxification is not only detrimental to the patient’s health but also unlikely to result in continued abstinence and long-term change.[134][135]
How to take a venous blood sample from the antecubital fossa using a vacuum needle.
How to record an ECG. Demonstrates placement of chest and limb electrodes.
How to obtain an arterial blood sample from the radial artery.
How to perform a femoral artery puncture to collect a sample of arterial blood.
Use of this content is subject to our disclaimer