Snapshot A 38-year-old man is brought to the emergency department after being in a motor vehicle accident. The patient fractured his femur and required surgery. On postoperative day 2, the patient reports trouble falling asleep, palpitations, and feeling anxious. Medical history is significant for hypertension and alcohol use disorder. His blood pressure is 165/98 mmHg, pulse is 105/min, and respirations are 20/min. Physical exam is significant for tremulousness and diaphoresis. He is started on lorazepam. Introduction Definition progression of signs and symptoms that occur after withdrawal from heavy and prolonged use of alcohol Epidemiology incidence typically seen in hospitalized patients who have alcohol dependence Pathogenesis prolonged use of alcohol downregulates GABA receptors and upregulates glutamate receptors in order to maintain arousal when alcohol is abruptly withdrawn, there is overexcitation of glutamate receptors Associated conditions Wernicke encephalopathy triad ophthalmoplegia encephalopathy ataxia thiamine and magnesium depletion results in necrosis of the mammillary bodies, thalamus, and hippocampus Korsakoff syndrome memory impairment and confabulations precipitated if giving dextrose prior to giving thiamine Prognosis alcohol withdrawal seizures and delirium tremens are life-threatening Presentation Symptoms/physical exam minor withdrawal anxiety agitation restlessness diaphoresis palpitations insomnia moderate-to-severe withdrawal hallucinations seizures delirium tremens Studies Labs thiamine and magnesium deficiency AST > ALT (2:1) serum γ-glutamyltransferase (GGT) a sensitive indicator of alcohol use Withdrawal Alcohol Withdrawal Time (Hours) Syndrome Clinical Findings 6-36 Minor withdrawal Anxiety Tremulousness Diaphoresis Palpitations 6-48 Seizures Tonic-clonic seizures short post-ictal period 12-48 Alcoholic hallucinosis Visual, auditory, and/or tactile hallucinationsnormal vital signs intact orientation normal vital signs 48-96 Delirium tremens Delirium Agitation Tachycardia Hypertension Fever Diaphoresis Treatment Medical thiamine indication to prevent Wernicke encephalopathy benzodiazepines indications the treatment of choice for alcohol withdrawal comments lorazepam and oxazepam are preferred in patients with liver disease Complications Cardiac arrhythmia Delirium tremens Tonic-clonic seizures