Name: Alcohol withdrawal — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

"Alcohol withdrawal" is a diagnosis of exclusion with no confirmatory test — and the things it hides (head bleed, sepsis, Wernicke, metabolic catastrophe) are what kill. The defensible chart shows you treated the withdrawal aggressively and ruled out the mimics, with thiamine given and a disposition that respects the risk of delirium tremens.

01What's at stake

Severe withdrawal carries real mortality, and delirium tremens — which can appear 2–4 days after the last drink — is a medical emergency that, treated late, kills, but with timely care approaches 0% mortality. Two failures dominate: anchoring on "just withdrawal" while missing a subdural or sepsis, and under-dosing sedation out of an unfounded fear of respiratory depression.

02The timeline

Early/minor (6–24h): tremor, anxiety, insomnia, nausea, autonomic signs (which beta-blockers can mask).
Alcoholic hallucinosis: hallucinations (often tactile) with an intact sensorium.
Withdrawal seizures (12–36h): usually brief and isolated; status is rare and should prompt a search for another cause.
Delirium tremens (~24–72h, lasting days): withdrawal + altered mentation, fever, severe agitation — and it can be quiet, without florid agitation or autonomic surges.

03The dangerous mimics — don't anchor

Occult head injury / subdural hematoma (falls). → CT head for AMS, seizure, trauma, delirium
CNS infection (meningitis/encephalitis), sepsis. → infection workup
Wernicke encephalopathy. → thiamine
Hypoglycemia, electrolyte/metabolic derangement (Mg, K, PO₄), alcoholic ketoacidosis, hepatic encephalopathy. → labs
Other ingestions / toxic alcohols; an elevated ethanol level does not exclude withdrawal. → broaden workup

Skip the typing

Work the case in the Alcohol Intoxication / Withdrawal Workup — it records glucose, the serial exam, CIWA, thiamine, head CT, and tox labs, and assembles an MDM that documents the mimics were excluded and withdrawal was treated.

04Assessment & treatment

CIWA-Ar guides symptom-triggered dosing (not valid in the sedated/intubated — use RASS). The best predictor of severe withdrawal is a prior history of it.
Symptom-triggered benzodiazepines, front-loaded — diazepam (fast, self-tapering) or lorazepam (preferred in severe liver disease); titrate to control. Patients need higher doses (down-regulated GABA receptors) — don't under-treat from respiratory fear.
Phenobarbital is an effective alternative/adjunct under protocol; propofol for the intubated, refractory patient; dexmedetomidine/ketamine are adjuncts that don't treat the underlying pathophysiology.
Antiseizure drugs (phenytoin) don't work for withdrawal seizures — use benzodiazepines/barbiturates.
Thiamine (IV; 500 mg if any Wernicke sign — the full triad is rare), magnesium, fluids; give thiamine before dextrose but don't delay dextrose for hypoglycemia.

05What to document

▼ weak

"Known alcoholic, tremulous, given Ativan ×1. Alcohol withdrawal. Discharged."

▲ defensible

"Tremor, anxiety, tachycardia ~10h after last drink; CIWA 14. Glucose normal. Considered and addressed mimics: no head trauma/focal deficit (low threshold for CT if altered), afebrile without infection source, no focal neuro signs; electrolytes and Mg checked; thiamine 100 mg IV given. Symptom-triggered diazepam titrated to control with serial CIWA; not under-dosed. Disposition per criteria; DT risk explained, suicidality screened, return precautions and follow-up arranged."

06Where charts fail

Attributing altered mental status to "withdrawal" without excluding subdural, sepsis, Wernicke, and metabolic causes.
Using an elevated ethanol level to dismiss withdrawal.
Under-dosing benzodiazepines out of unfounded respiratory-depression fear.
Copying prior-admission dosing despite kindling (escalating needs).
Skipping labs/thiamine, or discharging a confused "stable" DT patient to the floor instead of a monitored bed.

07Sources

Koo AY. Diagnosis and management of emergency department patients with alcohol withdrawal syndrome. Emergency Medicine Practice (EB Medicine). 2025;27(11).
Strayer RJ, Friedman BW, Haroz R, et al. ED management of patients with alcohol intoxication, withdrawal, and alcohol use disorder: AAEM white paper. J Emerg Med. 2023;64(4):517-540.
The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med. 2020;14(3S Suppl 1):1-72.
Rosenson J, Clements C, Simon B, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013;44(3):592-598.

Alcohol withdrawal: documentation that holds up