Delirium tremens or withdrawal seizures: a medical emergency. Give benzodiazepines, admit to a high-dependency setting, and give parenteral thiamine. Give thiamine before any glucose in the malnourished to avoid precipitating Wernicke.
Timeline
- Tremor, sweating, tachycardia, anxiety, nausea: 6 to 12 h after the last drink
- Withdrawal seizures: usually 12 to 48 h (generalised tonic-clonic)
- Delirium tremens: 48 to 72 h (confusion, hallucinations, autonomic instability, fever)
- DT carries significant mortality if untreated
Wernicke prophylaxis
- Parenteral thiamine (Pabrinex) for anyone malnourished or in significant withdrawal
- Give thiamine before carbohydrate or glucose
- Continue oral thiamine afterwards
Mild (CIWA under 10)
- Tremor, sweating, anxiety
- Symptom-triggered chlordiazepoxide
- Oral thiamine
Moderate to severe
- CIWA 10 or more, marked symptoms
- Reducing benzodiazepine regimen
- Parenteral thiamine (Pabrinex)
DTs / seizures
- Delirium tremens, hallucinations, seizures
- IV benzodiazepine, admit
- IV Pabrinex, treat complications
Treatment
1
1. Assess and score
Use CIWA-Ar (or a local scale) to guide symptom-triggered dosing. Fixed-dose reducing regimens are an alternative where monitoring is limited.
Use CIWA-Ar (or a local scale) to guide symptom-triggered dosing. Fixed-dose reducing regimens are an alternative where monitoring is limited.
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2
2. Benzodiazepines
Chlordiazepoxide or diazepam, titrated to symptoms, to prevent seizures and DT. Use shorter-acting lorazepam if significant liver impairment. Do not leave withdrawal untreated.
Chlordiazepoxide or diazepam, titrated to symptoms, to prevent seizures and DT. Use shorter-acting lorazepam if significant liver impairment. Do not leave withdrawal untreated.
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3
3. Thiamine and electrolytes
Parenteral thiamine (before glucose). Correct magnesium, phosphate and potassium; rehydrate.
Parenteral thiamine (before glucose). Correct magnesium, phosphate and potassium; rehydrate.
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4
4. Discharge and prevention
Refer to the alcohol liaison or community team, relapse prevention (acamprosate, naltrexone, or disulfiram), and follow-up. Treat coexisting depression.
Refer to the alcohol liaison or community team, relapse prevention (acamprosate, naltrexone, or disulfiram), and follow-up. Treat coexisting depression.
Watch for
- DT: a medical emergency needing admission
- Decompensated liver disease, pancreatitis, GI bleed
- Suicide risk and depression
Pitfalls
- Glucose before thiamine in the malnourished
- Under-treating withdrawal and allowing seizures or DT
- Over-sedation, especially with liver impairment
- Forgetting magnesium and phosphate
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026