emDOCs - May 16, 2022 - By Jack Yancey; Drew Micciche
Reviewed by: Todd Phillips; Alex Koyfman; Brit Long
Summary
- CNS hyperexcitation is the primary physiological abnormality seen in AWS
- AWS is a clinical diagnosis, and a diagnosis of exclusion. Consider other disease mimickers and rule them out during your workup
- Early diagnosis and treatment of AWS prevents symptom progression into life-threatening complications (withdrawal seizures, delirium tremens)
- Stages of AWS: withdrawal symptoms, hallucinations, withdrawal seizures, delirium tremens
- Benzodiazepines are the mainstay of treatment
- Patients with signs of mild withdrawal can be considered for discharge after receiving treatment
- Treat severe AWS with rapidly escalating doses of benzodiazepines to reduce risk of withdrawal seizures, delirium tremens, and need for intubation. Appropriate level of sedation is drowsy yet arousable
- Use phenobarbital for benzodiazepine-refractory AWS
Pearls/Pitfalls
- CIWA scores have questionable utility in the ED setting. They are nursing driven, and are not diagnostic for AWS.
- Inspect all patients for signs of head trauma and neurological deficits. Have a low threshold for CT head imaging
- Certain patients may develop withdrawal with mild to modestly elevated ethanol levels, however their clinical presentation and daily alcohol consumption should always be factored into the equation when determining whether the patient is in acute withdrawal.