Alcohol Withdrawal

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the November 2025 Emergency Medicine Practice article, Diagnosis and Management of Emergency Department Patients With Alcohol Withdrawal Syndrome

1. Epidemiology & Background

• Rising ED visits related to alcohol use.
• Mortality rates and spectrum of patient presentations.
• Importance of high suspicion and complexity of cases.
• Pathophysiology & Mechanisms
• Alcohol metabolism and neurochemical changes.
• Differential diagnosis: Conditions that mimic alcohol withdrawal.
• Prehospital & EMS Considerations
• Role of EMS in triage and initial management.
• Use of sobering centers vs. ED transport.
• Prehospital administration of benzodiazepines (IM midazolam).
• History & Risk Assessment
• Key questions to assess risk for alcohol withdrawal syndrome.
• Importance of patient history, medication use, and comorbidities.
• Discussion on patient honesty and rapport.
• Physical Exam & Scoring Systems
• DSM-5 criteria for alcohol withdrawal.
• Use of CIWA-AR, BAWS, and PAWSS scoring systems.
• Importance of objective measurement for monitoring and disposition.
• Complications & Special Presentations
• Complicated alcohol withdrawal: Hallucinosis, seizures, delirium tremens.
• Diagnostic workup: Labs, imaging, and co-ingestions.
• Special populations: End-stage liver disease, pregnancy, intubated patients.
• Treatment Strategies
• Mainstay: Benzodiazepines (types, dosing, and protocols).
• Phenobarbital: Indications, dosing, and evidence.
• Adjunctive therapies: Thiamine, glucose, magnesium.
• Alternative/adjunct medications: Gabapentin, ketamine, dexmedetomidine, baclofen.
• Clinical Pearls & Practice Changes
• Early, aggressive therapy to prevent complications.
• Symptom-based vs. fixed-schedule treatment.
• Gabapentin as an alternative or adjunct.
• Anti-craving medications for relapse prevention.
• Disposition & Protocols
• Use of scoring systems for safe discharge, observation, or admission.
• Importance of protocolized approaches and community resources.
• Summary & Take-Home Points
• Five key practice-changing points.
• Clinical pathway.

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