Acute abdomen and emergencies
Alcohol withdrawal and delirium tremens
Overview and approach
Alcohol withdrawal can progress to seizures and withdrawal delirium, a potentially fatal emergency.
- Symptoms and signs can start within hours of stopping after only a few weeks of heavy drinking. Spectrum: minor withdrawal (tremor, anxiety, sweats), seizures, alcoholic hallucinosis, and delirium tremens (DT) (original UpToDate-derived note).
- DT: agitation, disorientation, hallucinations and autonomic instability (tachycardia, hypertension, hyperthermia, diaphoresis); mortality up to 5%, higher if untreated. DT typically begins 48-72 hours after the last drink (1).
- Surgical relevance: admitted patients (including pre/post-operative) may withdraw 1-3 days after admission; inpatient care is recommended for predicted moderate/severe withdrawal, prior seizures/delirium or significant comorbidity (2).
Assessment and clinical features
Assess last alcohol use, previous severe withdrawal, autonomic signs, confusion, injury and coexisting illness.
- Risk factors for DT: sustained heavy drinking, previous DT, previous withdrawal seizures, age over 30, concurrent illness, significant withdrawal with an elevated ethanol level, more than two days between last drink and withdrawal onset. The best predictor of significant withdrawal is a PAWSS score of 4 or more.
- Symptoms: nausea/vomiting, tremor, sweats, anxiety, agitation, tactile/auditory/visual disturbance, headache, disorientation. Score with CIWA-Ar (mild under 10, moderate 10-20, severe over 20) where the patient can communicate (2)(3).
Differentials and investigations
Check glucose, electrolytes including magnesium/phosphate, organ function and competing delirium causes; symptom scores are limited in non-communicative/delirious patients.
- Alcohol withdrawal is a clinical diagnosis, but dangerous conditions can mimic or coexist with it: infection, trauma, metabolic derangement, drug overdose, hepatic failure, GI bleeding. Extensive testing (for example CT head or lumbar puncture) may be needed.
Management and follow-up
Monitored withdrawal treatment under protocol, thiamine and nutritional/electrolyte support; urgent senior care for severe withdrawal. Never delay treatment of hypoglycaemia to give thiamine first.
- Diazepam is the first-line drug in NSW guidance; loading is used for prior seizures or established withdrawal. If CIWA-Ar remains over 10 after 80 mg, a doctor should review to exclude other pathology (2)(3).
- Thiamine for all patients in withdrawal, given parenterally at first and before glucose where possible; higher-dose IV thiamine if Wernicke encephalopathy is suspected (2)(3)(4).
- DT needs high-dependency care, correction of electrolytes, and benzodiazepine sedation under senior guidance (2).
- Surgical care: involve addiction medicine/liaison early; plan analgesia and anaesthetic risk.
Red flags and clinical pearls
Delirium, seizures or escalating medication needs warrants high-acuity care. Do not assume every postoperative confused patient has withdrawal.
- Hypoglycaemia: give thiamine before glucose or as soon as possible after; do not delay glucose (1)(4).
- Alcohol is not an acceptable treatment for withdrawal (2).
- Viva: timing of withdrawal syndromes, DT features, why thiamine before glucose.
Delirium tremens
DT
Timing, pathophysiology, and emergency management table – Susceptibility to alcohol withdrawal and timing vary, but symptoms and signs can develop within hours of abstinence following as little as a few weeks of consistent, heavy alcohol use. A table summarizing the emergency management of moderate and severe alcohol withdrawal is provided (table 6). (See 'Pathophysiology' above.)
Dangerous diagnoses can mimic or coexist with alcohol withdrawal – Alcohol withdrawal remains a clinical diagnosis. It may be necessary to perform extensive testing (eg, lumbar puncture and cranial computed tomography [CT]) to rule out other diagnoses as many patients with alcohol use disorder do not stop drinking spontaneously and present with overt withdrawal symptoms that may mask other disorders. Conditions such as infection, trauma, metabolic derangements, drug overdose, hepatic failure, and gastrointestinal bleeding can mimic or coexist with alcohol withdrawal. (See 'Excluding alternative diagnoses' above.)
Symptoms of alcohol withdrawal – Alcohol withdrawal syndromes encompass symptoms ranging from mild tremulousness to life-threatening delirium tremens (DT). A table summarizing the timing of withdrawal symptoms is provided (table 1). (See 'Minor withdrawal symptoms' above and 'Withdrawal seizures' above and 'Alcoholic hallucinosis' above and 'Delirium tremens' above.)
Delirium tremens (DT) – DT is a syndrome characterized by agitation, disorientation, hallucinations, and autonomic instability (tachycardia, hypertension, hyperthermia, and diaphoresis) in the setting of acute reduction or abstinence from alcohol. DT is associated with a mortality rate of up to 5 percent, but the rate can be substantially higher if the condition goes untreated. Alcoholic hallucinosis and DT are distinct clinical entities. Patients at risk and those who fail to respond appropriately to initial doses of sedatives should be monitored closely and treated aggressively (table 3). (See 'Delirium tremens' above.)
Risk factors for DT include:
- A history of sustained drinking
- A history of DT
- A history of alcohol withdrawal seizures
- Age greater than 30
- The presence of a concurrent illness
- The presence of significant alcohol withdrawal in the presence of an elevated ethanol level
- A longer period (more than two days) between the last drink and the onset of withdrawal
The best predictor for clinically significant alcohol withdrawal is a score of 4 or higher on the Prediction of Alcohol Withdrawal Severity Scale (PAWSS)
Last updated from Sen’s notes on 9 October 2026.