Alcohol withdrawal and delirium tremens — CIWA, seizures, DT, thiamine (MEQ)

(i) Timeline and placement. Early autonomic features often from about 6–12 h after last drink; withdrawal seizures peak roughly 12–48 h; delirium tremens commonly 48–72 h (can later). At ~20 hours with a generalised seizure and marked autonomics, this is complicated alcohol withdrawal in the seizure window, still at risk of evolving DT over the next one to two days.[8]

(ii) Assessment. ABCDE, glucose, trauma survey. History: quantity, last drink time, prior seizures/DT, other substances (especially benzodiazepines), medical comorbidity. MSE and risk (suicide, absconding, capacity). Score CIWA-Ar (ten items, max 67) if assessable for symptom-triggered benzos; consider PAWSS for risk stratification in hospital protocols. Labs: U and E, Mg, phosphate, FBC, LFTs, coags; CT head if red flags (trauma, focal signs, first seizure with concern). Screen for infection if febrile later.[1][7][8]

(iii) Acute management. Admit to monitored setting. Benzodiazepines first-line — e.g. symptom-triggered diazepam 10–20 mg (or lorazepam 1–4 mg if liver disease) per CIWA protocol, titrated to control; fixed schedule if unassessable. Abort/prevent further seizures with adequate benzo cover (not phenytoin-first for pure AWS). Supportive care, electrolytes (Mg/K/phosphate). Thiamine: malnutrition raises Wernicke risk (Caine: any two of four features — treat early); give high-dose parenteral thiamine (EFNS-style 500 mg IV TDS for days then step-down per local protocol); co-cover when giving glucose.[2][4][5][6][7] Escalate if fluctuating consciousness and severe autonomics (DT) toward high-dose benzos and ICU-capable care.[3][8]

(iv) Inpatient criteria. Prior seizures/DT; high PAWSS or rising CIWA; acute medical illness; unstable housing/supports; pregnancy; polydrug (especially benzo) dependence; failed outpatient detox; inability to take oral meds safely.[7]

(v) Pitfalls. Undertreatment of withdrawal → further seizures/DT; antipsychotics-first for DT physiology; missed Wernicke waiting for classic triad; CIWA alone in unassessable patient; premature ambulatory discharge after complicated withdrawal.[3][5][8]