Alcohol withdrawal: benzos or phenobarbital.
The withdrawal timeline, the three scores (PAWSS, CIWA-Ar, RASS), two first-line pathways (benzodiazepines or phenobarbital), withdrawal seizures, thiamine before glucose, and delirium tremens.
Reviewed June 2026 · verify against current guidelines
Recognize & Stratify
Know the timeline.
Withdrawal timeline (from last drink)
| 6-36 h | Minor: tremor, anxiety, sweating, insomnia |
|---|---|
| 6-48 h | Generalized seizures; can begin as early as 2 h after the last drink |
| 12-48 h | Alcoholic hallucinosis, clear sensorium |
| 48-96 h | Delirium tremens |
Prior delirium tremens or withdrawal seizures predict severe withdrawal. Presenting >2 days after the last drink raises DT risk.
DT delirium tremens
Scoring Systems
Three scores, three jobs.
Match the tool to the task
| PAWSS | Predicts complicated withdrawal at admission. 10 items, max 10. Score ≥4 = high risk. |
|---|---|
| CIWA-Ar | Rates current severity in a communicative patient. 10 items, max 67. Give a dose at ≥8. |
| RASS | Sedation target, usable in any patient including intubated. Range +4 to -5; aim 0 to -1. |
CIWA-Ar severity bands: <10 minimal, 10-15 mild, 16-20 moderate, >20 severe.
PAWSS predicts, CIWA-Ar rates, RASS titrates. CIWA-Ar fails in delirium or intubation; use RASS.
PAWSS Prediction of Alcohol Withdrawal Severity ScaleCIWA-Ar Clinical Institute Withdrawal Assessment, revisedRASS Richmond Agitation-Sedation Scale
Two First-Line Pathways
Benzos or phenobarbital.
Two first-line pathways
| Benzo-first | Symptom-triggered (less drug, shorter stay): give a dose when CIWA-Ar ≥8, or titrate to a calm RASS. Diazepam 5-10 mg IV q5-10 min, chlordiazepoxide PO, or lorazepam in liver disease. Front-load high-risk; long half-life self-tapers. |
|---|---|
| Pheno-first | Load ~10 mg/kg IV over 30 min, then 130-260 mg IV PRN to RASS 0 to -1. Soft cap 20, hard cap 30 mg/kg. Long half-life self-tapers; minimize added benzodiazepines. |
Benzodiazepines are the traditional first-line. Some centers and clinicians use phenobarbital first-line.
Shared rules
- Never co-titrate benzodiazepines and phenobarbital (synergistic respiratory depression).
- Propofol if refractory (expect intubation). Gabapentin or carbamazepine for mild only.
Avoid as primary therapy: dexmedetomidine, clonidine, antipsychotics, ethanol, baclofen.
RASS Richmond Agitation-Sedation ScaleDT delirium tremens
Withdrawal Seizures
Benzos, not phenytoin.
What to know
- Usually a single seizure or brief flurry, with a short postictal period.
- Benzodiazepines, or phenobarbital, prevent recurrence; treat the withdrawal.
- Phenytoin does not work for withdrawal seizures. Skip it.
- Untreated, about 1 in 3 progress to delirium tremens.
Recurrent, focal, prolonged, or status seizures are not typical. Image and work up another cause.
Supportive Care & DTs
Protect the brain.
Every patient
- IV thiamine before glucose: 100-200 mg to prevent, 500 mg TID to treat Wernicke.
- Wernicke triad: confusion, ophthalmoplegia or nystagmus, ataxia; often incomplete, so treat empirically.
- Replete magnesium, phosphate, potassium, and folate; correct volume.
Delirium tremens
| Recognize | Delirium plus autonomic storm, 48-96 h out |
|---|---|
| Treat | Escalating IV benzodiazepines, add phenobarbital, ICU |
Escalate to ICU
| ICU if | Age >65, cardiac disease or instability, severe electrolyte or acid-base derangement, respiratory failure, hyperthermia >39°C, rhabdomyolysis or renal failure, prior DT, or high or continuous sedative needs. |
|---|
Delirium tremens is a clinical diagnosis and an emergency. Treated mortality is under 5%, untreated far higher.
DT delirium tremensTID three times daily
Pitfalls & Disposition
Where teams slip.
- Giving glucose before thiamine, precipitating Wernicke.
- Fixed tapers that under-treat the sick and over-sedate the stable.
- Using CIWA-Ar in the delirious or non-verbal; use RASS instead.
- Relying on dexmedetomidine or antipsychotics; they miss seizures and DT.
- Anchoring on withdrawal without excluding mimics: infection, bleed, trauma.
- Discharging high-risk patients without follow-up or thiamine.
Severe withdrawal, delirium tremens, or seizures: admit, treat parenterally, escalate to ICU.
RASS Richmond Agitation-Sedation ScaleDT delirium tremens
Sources
Verify against current guidelines and local protocol before acting.
- American Society of Addiction Medicine. The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. J Addict Med 2020;14(3S):1-72 (updated 2023).
- Sullivan JT et al. Assessment of alcohol withdrawal: the revised CIWA-Ar. Br J Addict 1989;84:1353-1357.
- Maldonado JR et al. Prediction of Alcohol Withdrawal Severity Scale (PAWSS): validation. Alcohol 2015;49:375-390.
- Hoffman RS, Weinhouse GL. Management of moderate and severe alcohol withdrawal syndromes. UpToDate; review through May 2026.
- Farkas J. Alcohol withdrawal. EMCrit Internet Book of Critical Care (IBCC); phenobarbital protocol, RASS titration.
- Latt N, Dore G. Thiamine in the treatment of Wernicke encephalopathy in patients with alcohol use disorders. Intern Med J 2014.
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