Alcohol intoxication and withdrawal

Manage now— do this, in order

• Position and protect the airway first — airway compromise, not alcohol, kills: nurse the obtunded unintubated patient left lateral (recovery) with suction available, never supine and never unobserved; definitive airway protection for GCS 8 or less, absent gag or repeated vomiting.
• Thiamine before any glucose-containing solution (glucose consumes residual thiamine and may precipitate Wernicke's). Suspected/possible Wernicke's (any confusion, eye sign or ataxia; coma; DTs): 500 mg IV three times daily for 2–3 days, then 250 mg IV/IM daily for 5 days, then oral 100 mg daily. Prophylaxis in any dependent or malnourished drinker: 250 mg parenterally daily for 3–5 days. Dilute parenteral doses in 50–100 mL and infuse over ~30 minutes; oral thiamine is not adequate for suspected Wernicke's.Doctor / Nurse
• Treat documented symptomatic hypoglycaemia immediately even so: 25% glucose 100 mL (or 50% glucose 50 mL) slow IV into a large well-running cannula, then a 10% glucose infusion; recheck at 10 minutes then hourly. Children: 10% glucose 2 mL/kg then a 10% infusion — never concentrated 50% glucose in a small child.Doctor / Nurse
• Symptom-triggered dosing where the patient can be scored: CIWA-Ar hourly; at 8 or above give chlordiazepoxide 20–30 mg orally, diazepam 10 mg orally, or lorazepam 1–2 mg orally (liver disease or the elderly); rescore in an hour and repeat while 8 or above. Before every dose: patient rousable, respiratory rate 12 or more, no new focal neurology.Doctor / Nurse
• Fixed-dose reducing regimen where the patient cannot be scored (see chart): chlordiazepoxide 20–30 mg four times daily on day 1 tapering to 10 mg twice daily on day 5, then stop, with an as-required dose for breakthrough; reduce doses by a third to a half in the elderly, frail, respiratory or hepatic impairment, or change to lorazepam. Where the oral route is unavailable: diazepam 10 mg slow IV at no more than 5 mg/minute, or lorazepam 2 mg IV/IM — never diazepam intramuscularly.Doctor / Nurse
• Withdrawal seizure: protect the head, left lateral, oxygen, suction, check glucose during the seizure. If over five minutes or a second fit without recovery: lorazepam 4 mg IV over 2 minutes (repeatable once after 10 minutes), diazepam 10 mg IV at no more than 5 mg/minute, or — without access — midazolam 10 mg buccal/IM. Paediatric: lorazepam 0.1 mg/kg IV (max 4 mg), diazepam 0.1–0.3 mg/kg IV (max 10 mg) or 0.5 mg/kg rectally, midazolam 0.3 mg/kg buccal (max 10 mg). Phenytoin neither prevents nor treats these seizures.Doctor / Nurse
• Delirium tremens — IV benzodiazepine titrated to effect, in doses substantially larger than ordinary withdrawal: front-load diazepam 10 mg slow IV over at least two minutes, repeated every 5–10 minutes, or lorazepam 2–4 mg IV every 10–15 minutes in liver disease or the elderly. Endpoint: light sleep from which the patient rouses to voice — not unconsciousness, not a fixed cumulative dose. Under-treatment is the commoner and more dangerous error.Doctor / Nurse
• Support DTs as hard as you sedate: 0.9% sodium chloride titrated to pulse, BP and hourly urine output; treat hyperthermia actively (a genuine cause of death); glucose hourly; magnesium sulfate 2 g (8 mmol) IV in 100 mL 0.9% sodium chloride over 20–30 minutes where the level is low or tremor persists; high-dose parenteral thiamine for every patient in DTs. Never attribute fever to withdrawal without a septic screen.Doctor / Nurse
• Never: flumazenil (may precipitate uncontrollable seizures); diazepam intramuscularly; an antipsychotic as a substitute for benzodiazepine (haloperidol 2.5–5 mg IM/slow IV with an ECG is an adjunct only); beta-blockers or clonidine as monotherapy; hyponatraemia corrected faster than ~8 mmol/L in 24 h and 15 mmol/L in 48 h (osmotic demyelination).