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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Withdrawal begins 6-24 h; seizures 12-48 h; DTs usually 48-96 h
- Symptoms include tremor, anxiety, insomnia, nausea, diaphoresis, tachycardia, hypertension, hallucinosis, seizures, delirium
- Benzodiazepines are first-line; lorazepam if liver disease/older/frail
- Thiamine before glucose in malnourished/high-risk patients
- DTs require ICU-level care and can be fatal
Overview
Alcohol withdrawal results from abrupt reduction in alcohol intake after chronic exposure, causing unopposed CNS excitation. Alcohol hallucinosis has hallucinations with relatively clear sensorium; DTs have delirium and severe autonomic instability.
Epidemiology
Severe withdrawal is predicted by prior withdrawal seizures/DTs, heavy daily use, older age, medical illness, electrolyte abnormalities, dehydration, sedative co-use, and prolonged time since last drink.
Clinical Features
Symptoms
Tremor, anxiety, insomnia, nausea, vomiting
Tachycardia, hypertension, diaphoresis, fever
Visual/tactile hallucinations with clear sensorium early
Generalized tonic-clonic seizures 12-48 h after last drink
DTs: fluctuating confusion, severe agitation, hallucinations, fever, autonomic instability
Signs
Coarse tremor, diaphoresis, tachycardia, hypertension
Disorientation, inattention, agitation, visual hallucinations
Ophthalmoplegia/nystagmus, ataxia, confusion suggests Wernicke
Trauma, GI bleed, pancreatitis, infection, liver failure signs
Investigations
First-line
CIWA-Ar/objective scaleGuides symptom-triggered therapy when patient is communicative
Basic labsCMP, Mg, phosphate, glucose, CBC, LFTs, INR, ethanol, pregnancy test
Evaluate mimicsHead trauma, sepsis, hepatic encephalopathy, hypoglycemia, pancreatitis, GI bleed, other withdrawal
Second-line
ECG/telemetryQT prolongation, arrhythmias, electrolyte abnormalities
CT headTrauma, focal deficits, anticoagulation, persistent altered mental status
ToxicologyPolysubstance use or unclear presentation
Specialist
ICUDTs, refractory withdrawal, severe autonomic instability, repeated seizures, high-dose sedatives
Addiction medicineAUD treatment planning after stabilization
1
Stabilization
- ABCs, vitals, IV access, glucose, fluids, correct Mg/K/phosphate
- Thiamine before glucose; higher-dose thiamine if Wernicke suspected
- Treat trauma, infection, pancreatitis, GI bleed, hepatic encephalopathy concurrently
2
Benzodiazepines
- Symptom-triggered therapy with CIWA-Ar when reliable
- Diazepam/chlordiazepoxide give smoother course; lorazepam for liver disease, older adults, frailty
- Fixed-dose taper when CIWA unreliable
3
Severe withdrawal/DTs
- ICU with high-dose benzodiazepines; phenobarbital by experienced protocols
- Antipsychotics only adjunctively after adequate benzodiazepines; they do not prevent seizures
- Start relapse-prevention planning after stabilization
Complications
- Withdrawal seizures:
- Delirium tremens:
- Wernicke encephalopathy:
- Aspiration and trauma:
- Hypomagnesemia, hypokalemia, hypophosphatemia:
- Rhabdomyolysis and arrhythmias:
USMLE Step 2 CK Exam Tips
- 1Seizures 12-48 h; DTs 48-96 h
- 2First-line is benzodiazepines, not antipsychotics
- 3Lorazepam preferred in liver disease
- 4Thiamine before glucose
- 5Clear sensorium hallucinosis vs delirious DTs
- 6Phenobarbital is severe/refractory or protocolized care
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