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Clinical Atlas Prestige · Evidence-first

Psych VivasAddiction psychiatry

Psych Vivas · Addiction psychiatry

Alcohol withdrawal and delirium tremens — structured clinical viva

Fellowship viva on DT recognition, CIWA limits, high-dose benzodiazepines, antipsychotics-not-first-line, Wernicke/thiamine, and inpatient escalation.

clinical
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Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar on call. A 49-year-old with alcohol dependence is day two on the medical ward (last drink ~55 hours ago). He is sweaty, HR 128, BP 170/100, fluctuating orientation, pulling at lines, describing animals in the room. The medical team gave 2.5 mg oral diazepam once and now wants regular olanzapine for 'psychosis'. They ask whether CIWA of 8 measured when he was obtunded after the seizure earlier means he is fine. Defend diagnosis, differentials, emergency pharmacology with doses, thiamine strategy, and why the current plan is unsafe.

Interpretation

Reveal interpretation

Diagnosis. Delirium tremens — ~55 hours after last drink, fluctuating consciousness, severe autonomic hyperactivity, formed hallucinations. This is a medical emergency, not primary schizophrenia-spectrum psychosis.[1][2]

Differential. Medical delirium (infection, metabolic, head injury), Wernicke encephalopathy (may coexist), alcohol hallucinosis without delirium (sensorium clearer), benzo withdrawal if co-dependent, hepatic encephalopathy if cirrhotic.[2][7]

CIWA issue. A score obtained while obtunded is not reliable. CIWA-Ar requires an assessable patient; do not withhold treatment based on a falsely low score.[3][6]

Unsafe plan. Tiny single-dose oral diazepam under-treats DT; olanzapine monotherapy does not fix withdrawal hyperexcitability. Need aggressive benzodiazepine titration (often parenteral; e.g. repeated diazepam or lorazepam doses per protocol until calm and autonomics improve), continuous monitoring, ICU if refractory/respiratory risk, electrolytes, and parenteral thiamine (high-dose EFNS-style, e.g. 500 mg IV TDS initially when Wernicke risk).[1][4][5][6]

Escalating viva probes

ProbeModel point
DT timingCommonly 48–72 h after last drink
First-line DT drug classBenzodiazepines / cross-tolerant sedative-hypnotics
CIWA-Ar max67 (ten items)
Caine ruleAny 2 of 4 → treat as Wernicke
Liver failure agentPrefer lorazepam (or oxazepam) over diazepam
Antipsychotics roleAdjunct after GABA cover, not monotherapy
[1] [2] [3] [5] [6]

Key points

  • Map last drink → seizure/DT windows.
  • Treat DT physiology with adequate benzos; escalate level of care early.
  • Never trust CIWA on an unassessable patient.
  • Parenteral thiamine for Wernicke risk without waiting for the triad.
  • Plan addiction aftercare only after medical stabilisation.
[1] [2] [3] [5] [6]

References

  1. [1]Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med, 2004.PMID 15249349
  2. [2]Schuckit MA Recognition and management of withdrawal delirium (delirium tremens). N Engl J Med, 2014.PMID 25427113
  3. [3]Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict, 1989.PMID 2597811
  4. [4]Mayo-Smith MF Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. JAMA, 1997.PMID 9214531
  5. [5]Galvin R, Bråthen G, Ivashynka A, et al. EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. Eur J Neurol, 2010.PMID 20642790
  6. [6]ASAM The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. J Addict Med, 2020.PMID 32511109
  7. [7]Caine D, Halliday GM, Kril JJ, et al. Operational criteria for the classification of chronic alcoholics: identification of Wernicke's encephalopathy. J Neurol Neurosurg Psychiatry, 1997.PMID 9010400