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VI. Addressing Complicated Alcohol Withdrawal
A. Alcohol Withdrawal Seizure
(1) Monitoring
Î Recommendation VI.1: Patients should be monitored for alcohol
withdrawal seizures even in the absence of other clinically prominent
alcohol withdrawal signs or symptoms.
Î Recommendation VI.2: Following an alcohol withdrawal seizure,
patients should be admitted to a setting with close monitoring
available and should be re-assessed every 1–2 hours for 6–24 hours.
Patients should be closely monitored for delirium and the need to
receive intravenous (IV) fluids, due to potential electrolyte imbalances.
(2) Supportive care
Î Recommendation VI.3: If available and applicable, existing
institutional/hospital-associated delirium protocols can be used for
supportive care of patients with an alcohol withdrawal seizure.
(3) Pharmacotherapy
Î Recommendation VI.4: Following a withdrawal seizure, patients
should be immediately treated with a medication effective at
preventing another seizure. Benzodiazepines are first-line treatment,
and a fast-acting agent such as lorazepam or diazepam is preferred.
Phenobarbital is also an option, but benzodiazepines are preferred.
Î Recommendation VI.5: Following a withdrawal seizure, parenteral
administration of medications is preferred. If available, IV
administration is preferred to intramuscular (IM), but IM
administration is also effective. Parenteral phenobarbital should be
used only in highly supervised settings (e.g., Intensive Care Unit [ICU],
CCU) because of risk of over-sedation and respiratory depression.
Î Recommendation VI.6: It is not recommended to use alpha2-
adrenergic agonists or beta-adrenergic antagonists to prevent or
treat alcohol withdrawal seizures because they are ineffective for
this purpose. Beta-adrenergic antagonists also can lower the seizure
threshold. Phenytoin should not be used unless treating a concomitant
underlying seizure disorder.
Treatment
