Alcohol Withdrawal / Delirium Tremens — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Withdrawal severity
   Withdrawal severity (CIWA-Ar, any DTs)? (Onset 6–8 h after the last drink (anxiety, tremor, sweating, tachycardia, low-grade fever), peaking at 24–72 h; complications include withdrawal seizures (12–48 h) and delirium tremens (DTs, 48–96 h, altered mentation + autonomic hyperactivity + agitation, can be fatal). Use the CIWA-Ar scale. All patients: thiamine before glucose (prevent Wernicke), folate, and magnesium/potassium/phosphate repletion.)
   • Severe / DTs / seizures → Severe / DTs
   • Mild–moderate (CIWA-Ar assessable) → Mild–moderate
2. [End] Mild–moderate
   Symptom-triggered benzodiazepines by CIWA-Ar (dose at score ≥8–10, reassess q1h — uses less total drug and shorter duration than fixed dosing); for those who cannot be reliably assessed (delirium/uncooperative/high-risk) use a fixed-dose regimen. Long-acting benzodiazepines (diazepam/chlordiazepoxide) give a smoother course; use lorazepam/oxazepam in liver disease. Thiamine, fluids, monitoring, a quiet environment.
3. [End] Severe / DTs
   Severe/delirium tremens (DTs)/withdrawal seizures: ICU monitoring; aggressive IV benzodiazepines (symptom-triggered or loading), escalate if refractory and add phenobarbital, dexmedetomidine/propofol as adjuncts (not alone); thiamine before glucose, correct magnesium/potassium/phosphate; treat precipitants and comorbidities. DTs has high mortality — monitor airway and circulation closely.

Source guidelines & references

• CIWA-Ar scale; management of alcohol withdrawal syndrome (CCJM/ASAM)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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