Skills
Alcohol Withdrawal - CE
Extended Text
ALERT
Delirium tremens (DT) is a medical emergency that occurs in heavy drinkers 24 to 72 hours after the last ingestion of alcohol.10 DT is
preventable if early symptoms of alcohol withdrawal are detected and treated. Individuals experiencing DT require aggressive monitoring and
treatment of associated symptoms (e.g., seizures, tachycardia, tachypnea, hyperpyrexia, delusions, disorientation, hallucinations, confusion,
impaired attention, increased motor activity). Ensuring adequate monitoring of nutrition, vital signs, fluid and electrolyte balance, patient
safety, and medications is essential.1
OVERVIEW
Alcohol use disorder consists of a combination of behavioral and physical symptoms, including withdrawal, tolerance, and craving. For
individuals who drink alcohol excessively, withdrawal may follow a period of abstinence within 4 to 12 hours of the last drink.2 The more one
drinks, the more likely symptoms of withdrawal will appear after drinking stops. According to The American Psychiatric Association's
Diagnostic and Statistical Manual of Mental Disorders (5th ed.) (DSM-5), symptoms of alcohol withdrawal include at least two of these:2
• Autonomic hyperactivity (e.g., diaphoresis or pulse rate greater than 100 beats per minute)
• Increased hand tremor
• Insomnia
• Nausea or vomiting
• Transient visual, tactile, or auditory hallucinations or illusions
• Psychomotor agitation
• Anxiety
• Generalized tonic-clonic seizures
The progression of alcohol withdrawal syndrome can be divided into three stages.
• Stage I includes mild symptoms such as anxiety, tremor, insomnia, headache, heart palpitations, and gastrointestinal disturbances.
• Stage II consists of moderate symptoms of diaphoresis, increased systolic blood pressure, tachypnea, tachycardia, confusion, and mild
hyperthermia.
• Stage III is the most severe, with symptoms consistent with DT, including disorientation, impaired attention, visual or auditory
hallucinations (or both), and seizures.10
Symptom management and prevention of DT are goals in the care of patients experiencing alcohol withdrawal. Interventions include
conducting a thorough assessment and patient history of alcohol abuse, maintaining the patient’s and health care team members’ safety,
administering and monitoring treatment medications, and monitoring fluid and electrolyte status. The risk of symptom severity and
subsequent recommended treatment can be determined using an alcohol withdrawal scale, such as the Clinical Institute Withdrawal
Assessment of Alcohol Scale, Revised (CIWA-Ar) (Figure 1).5,6
Medications such as chlordiazepoxide, lorazepam, haloperidol, thiamine (vitamin B1), and diphenhydramine are commonly used in the
treatment of alcohol withdrawal. Benzodiazepines, such as chlordiazepoxide and lorazepam, are given to decrease anxiety, psychomotor
agitation, restlessness, and withdrawal symptoms caused by a decrease in or cessation of alcohol intake. Thiamine (vitamin B1) is given to
correct deficiencies caused by poor nutrition and disruption of thiamine metabolism as a result of long-term alcohol dependence.1,13
SUPPLIES
See Supplies tab at the top of the page.
EDUCATION
• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall
neurologic and psychosocial state.
• Educate the patient and family regarding the symptoms of alcohol withdrawal.
• Educate the patient and family about the negative effects of alcohol on the body (e.g., vitamin deficiencies, memory impairment,
cognitive slowing).
• Teach the patient and family about the importance of limiting contact with others who are drinking alcohol.
• Inform the patient about treatment options for alcohol abuse (e.g., disulfiram, naltrexone, acamprosate medication therapy, outpatient
treatment, therapy groups, residential treatment programs).
• Educate the patient about the names and actions of all treatment medications and their potential side effects.
• Inform the patient about the hazards of drinking alcohol while taking prescription medications.
• Inform the family about community support groups (e.g., 12-step programs).
• Encourage questions and answer them as they arise.
ASSESSMENT
1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for
isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an organization-approved standardized tool for
suicide assessment.9
5. Assess the patient’s alcohol intake history.
Rationale: Recording alcohol history assists in formulating an appropriate plan of
care for the patient and provides a means of communication needed to inform all
members of the treatment team.
a. Consider using a standardized tool such as the CAGE questionnaire (Figure 2).
b. Determine the amount, frequency, and length of time patient has been drinking and the time and amount of the last
alcoholic drink.5,8
c. Include any history of blackouts, seizures, and withdrawal symptoms.
d. Include any history of alcohol dependency and previous treatment.5,6
Rationale: A history of alcohol-related seizures and alcohol dependency
increases the probability of the patient experiencing alcohol-related seizures
and DT.6
6. Assess the patient for symptoms of alcohol withdrawal (e.g., abnormal vital signs, nausea, tremors, psychomotor agitation, anxiety,
hallucinations, seizures).
a. Evaluate the severity of symptoms.
b. Consider using a standardized protocol such as the CIWA-Ar scale for alcohol withdrawal symptoms (Figure 1).4,6
7. Assess the patient for coexisting health problems (e.g., vitamin and mineral deficiency anemia, diabetes, hypertension, depression).
8. Assess fluid and electrolyte status by examining laboratory results and monitoring intake and output.
9. Assess the patient’s hydration status.
10. Assess and monitor the patient’s orientation and mental status, including level of anxiety.
11. Assess the patient’s need for medication according to the organization’s practice or prescribed regimen.
12. Assess the patient for specific contraindications to receiving treatment medications and advise the practitioner accordingly.
13. Assess the patient’s understanding and knowledge of disease processes related to excessive drinking and willingness to make lifestyle
changes.
14. Assess the patient’s support systems and barriers to treatment.
15. Assess the patient for symptoms of depression and other signs and symptoms of mental disorders.
16. Assess the need for a psychiatric practitioner consult and seek a consult as appropriate.
STRATEGIES
1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily
fluids.
2. Verify the correct patient using two identifiers.
3. Explain the strategies and ensure that the patient agrees to treatment.
4. Determine the extent of alcohol intake.
Rationale: All health care team members are responsible for assessing the alcohol
intake status of patients. The extent of alcohol intake must be determined to provide
effective monitoring and interventions and to prevent serious consequences, such as
DT.
5. Based on results of the patient’s assessment, initiate the organization’s alcohol withdrawal practices when indicated.
Rationale: Alcohol withdrawal can be complicated by medical conditions such as
infections, hypertension, liver disease, and hypoglycemia.8
Be aware that DT can cause death if left untreated.
6. Based on the most recent alcohol intake, monitor the patient’s vital signs in accordance with the organization’s alcohol withdrawal
practices.8
Be aware that the patient may be at risk for medical complications. Seek
interventions as appropriate for elevated heart rate and blood pressure.
7. Obtain an accurate medical and psychiatric history from the patient, including illnesses that are related to alcohol use (e.g., Wernicke
encephalopathy) as well as those that may be complicated by excessive alcohol intake (e.g., diabetes mellitus). In addition to medical
complications, alcohol withdrawal can lead to psychiatric complications such as agitation, perceptual disturbances, and paranoia.6
8. Monitor the patient’s fluid and electrolyte status.
a. Encourage the patient to increase oral fluid intake to prevent dehydration.
b. Administer IV fluids as ordered if the patient is medically unstable.
Rationale: Adequate hydration promotes homeostasis and prevents
dehydration.
c. Maintain adequate fluid and nutritional intake to facilitate excretion and to decrease blood alcohol levels for a patient
admitted with recent alcohol intake.
Rationale: Heavy drinkers are commonly malnourished and can easily become
dehydrated during the withdrawal period.
9. Inform the patient of signs and symptoms of alcohol withdrawal (e.g., tremors, restlessness, nausea, diaphoresis) and encourage the
patient to report symptoms.
Rationale: The patient may or may not be aware of the symptoms associated with
acute alcohol withdrawal. Reminding the patient of the symptoms and encouraging
the patient to report symptoms facilitates early intervention.
10. Consider seizure precautions in the patient who reports heavy or frequent alcohol use. Initiate seizure precautions for a patient who
has a history of alcohol dependency and alcohol-related seizures or history of blackouts.
Rationale: Patients with a history of alcohol dependency are at risk for seizures,
especially when abstaining during an inpatient stay. Close monitoring and use of
elevated, padded side rails ensure patient safety.
11. Be aware that the patient may be experiencing medical issues not directly related to alcohol withdrawal (e.g., exacerbation of a
chronic illness). Thoroughly investigate all medical problems, especially those that seem unrelated to alcohol withdrawal (e.g.,
excessive sleepiness, difficulty breathing).
12. Administer all medications prescribed to treat the symptoms of alcohol withdrawal.
13. Use a nonjudgmental attitude to build rapport to encourage the patient to report mental health issues (e.g., depression, anxiety, or
suicidal ideation).
Rationale: Many patients with a history of excessive alcohol use have comorbid
mental health issues. Building rapport and demonstrating a nonjudgmental attitude
helps to establish a trusting relationship with the patient and family. Patients are
more likely to respond positively to a therapeutic approach. All patients with mental
health issues should be screened for suicidal ideation, regardless of current medical
problems.
14. Once rapport has been established, engage the patient in a discussion about the consequences of alcohol use. Use open-ended
questions to assess the patient’s knowledge of the disease process and willingness to make lifestyle changes.
15. Explore support systems available to the patient, including family members, case managers, and local or national groups (e.g., 12-
step program). Problem solve around barriers to treatment.
Rationale: Engaging the patient in discussions about possible resources encourages
patient involvement and investment in treatment.
16. Remove PPE and perform hand hygiene.
17. Document the strategies in the patient's record.
REASSESSMENT
1. Monitor the patient’s vital signs and reassess using a tool such as the CIWA-Ar, or in accordance with the organization’s practice
regarding alcohol withdrawal.4,7
2. Monitor for other clinically relevant symptoms of withdrawal, such as diaphoresis, agitation, tremor, or sensory disturbances.
3. Reassess vital signs after administering medications to determine medication effectiveness.
4. Assess the patient’s level of alertness following medication administration in order to keep the patient mildly sedated while still
allowing for easy arousal.13
5. Reassess the patient’s mental health status during detoxification.
6. Assess, treat, and reassess pain.
EXPECTED OUTCOMES
• Patient's hydration is maintained.
• Patient's vital signs are in the normal range.
• Patient exhibits no symptoms of alcohol withdrawal or withdrawal delirium.
• Patient maintains a balanced diet.
• Patient states negative effects of alcohol on the body.
• Patient states negative effects of alcohol on physical, occupational, and social functioning.
• Patient's laboratory results exhibit normal values.
• Patient remains free from suicidal or self-harm ideations.
• Patient verbalizes a plan to attend a 12-step program or other support group.
• Patient verbalizes need for follow-up care with a mental health practitioner.
UNEXPECTED OUTCOMES
• Patient exhibits symptoms of alcohol withdrawal or DT.
• Patient experiences alcohol-related seizures.
• Patient experiences medical complications resulting from alcohol use.
DOCUMENTATION
• Vital signs
• Fluid and electrolyte status
• Institution of seizure precautions
• Alcohol intake history, alcohol-related seizures, and previous treatment for alcohol-related problems
• Interventions related to assessment and treatment of alcohol withdrawal
• Scores measured on standardized tools such as CAGE questionnaire and CIWA-Ar if used, or scores per the organization's practice
• Education
• Nutritional intake
• Medication administered to treat alcohol withdrawal
• Patient's response to medications, including any adverse reactions
• Unexpected outcomes and related interventions
ADOLESCENT CONSIDERATIONS
• Adolescents who have experienced neglect or emotional abuse during childhood are at higher risk for alcohol use.12
• Alcohol screening is warranted in an adolescent who has a history of drinking alcohol.
• Adolescents should be screened for alcohol abuse, especially if the parents drink or if alcohol is available in the home.3
OLDER ADULT CONSIDERATIONS
• Alcohol dependency is often underdiagnosed and undertreated in older adults, partially because of similarities with age-related
diagnoses (e.g., dementia) and symptoms (e.g., unsteady gait).
• Older adults may experience adverse effects when consuming medications with alcohol because of declining renal function, poor
nutrition, impaired drug metabolism, or other causes.
• In most cases, older adults have higher rates of medical comorbidities and are at higher risk of experiencing DT.11
• Dementia related to chronic alcohol dependency may occur in older adults.
• Excessive drinking in older adults increases their susceptibility to falls, accidents, and complications with medical conditions.
SPECIAL CONSIDERATIONS
• Drinking during pregnancy may cause birth defects and fetal alcohol syndrome.14
• Many patients with psychiatric conditions self-medicate with alcohol to decrease anxiety. Some people with mental illness have a
secondary diagnosis of alcohol abuse. These patients may experience alcohol withdrawal when heavy drinking is decreased or stopped.
• Patients with depression may also become suicidal while under the influence of alcohol.
• Military veterans and others suffering from posttraumatic stress disorder may be at risk for excessive alcohol use to cope with
flashbacks, nightmares, and intrusive memories.
REFERENCES
1. Airagnes, G. and others. (2019). Alcohol withdrawal syndrome management: Is there anything new? La Revue de Medecine Interne,
40(6), 373-379. doi:10.1016/j.revmed.2019.02.001
2. American Psychiatric Association (APA). (2013). Alcohol withdrawal: Diagnostic features. In DSM-5: Diagnostic and statistical manual
of mental disorders (5th ed., pp. 499-502). Washington, DC: Author. (classic reference)* (Level VII)
3. Cox, M.J. and others. (2018). Parental drinking as context for parental socialization of adolescent alcohol use. Journal of Adolescence,
69, 22-32. doi:10.1016/j.adolescence.2018.08.009 (Level VI)
4. Eloma, A.S. and others. (2018). Evaluation of the appropriate use of a CIWA-Ar alcohol withdrawal protocol in the general hospital
setting. The American Journal of Drug and Alcohol Abuse, 44(4), 418-425. doi:10.1080/00952990.2017.1362418 (Level VI)
5. Glann, J.K. and others. (2019). Alcohol withdrawal syndrome: Improving recognition and treatment in the emergency department.
Advanced Emergency Nursing Journal, 41(1), 65-75. doi:10.1097/TME.0000000000000226 (Level VI)
6. Grover, S., Ghosh, A. (2018). Delirium tremens: Assessment and management. Journal of Clinical and Experimental Hepatology, 8(4),
460-470. doi:10.1016/j.jceh.2018.04.012
7. Holt, C. and others. (2017). Implementing an alcohol withdrawal protocol: A quality improvement project. Journal of Nursing Care
Quality, 32(3), 234-241. doi:10.1097/NCQ.0000000000000231
8. Jesse, S. and others. (2017). Alcohol withdrawal syndrome: Mechanisms, manifestations, and management. Acta Neurologica
Scandinavica, 135(1), 4-16. doi:10.1111/ane.12671
9. Joint Commission, The. (2021). National Patient Safety Goals® for the hospital program. Retrieved May 19, 2022, from
https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-
goals/2022/npsg_chapter_hap_jan2022.pdf (https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-
safety-goals/2022/npsg_chapter_hap_jan2022.pdf ) (Level VII)
10. Moore, D.T., Fuehrlein, B.S., Rosenheck, R.A. (2017). Delirium tremens and alcohol withdrawal nationally in the Veterans Health
Administration. The American Journal on Addictions, 26(7), 722-730. doi:10.1111/ajad.12603 (Level VI)
11. Mulkey, M.A., Olson, D.M. (2020). Delirium tremens in the older adult. The Journal of Neuroscience Nursing, 52(6), 316-321.
doi:10.1097/JNN.0000000000000543
12. Wlodarczyk, O. and others. (2017). Protective mental health factors in children of parents with alcohol and drug use disorders: A
systematic review. PloS One, 12(6), e0179140. doi:10.1371/journal.pone.0179140 (Level I)
13. Wong, J. and others. (2020). The ASAM clinical practice guideline on alcohol withdrawal management. Journal of Addiction Medicine,
14(3S Suppl. 1), 1-72. doi:10.1097/ADM.0000000000000668 Retrieved May 19, 2022, from https://www.asam.org/docs/default-
source/quality-science/the_asam_clinical_practice_guideline_on_alcohol-1.pdf?sfvrsn=ba255c2_2
(https://www.asam.org/docs/default-source/quality-science/the_asam_clinical_practice_guideline_on_alcohol-1.pdf?
sfvrsn=ba255c2_2) (Level VII)
14. Wozniak, J.R., Riley, E.P., Charness, M.E. (2019). Clinical presentation, diagnosis, and management of fetal alcohol spectrum
disorder. The Lancet. Neurology, 18(8), 760-770. doi:10.1016/S1474-4422(19)30150-4
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and
may also represent the foundational research for practice.
Elsevier Skills Levels of Evidence
• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports
