In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the November 2025 Emergency Medicine Practice article, Diagnosis and Management of Emergency Department Patients With Alcohol Withdrawal Syndrome

Epidemiology & Background

Rising ED visits related to alcohol use.
Mortality rates and spectrum of patient presentations.
Importance of high suspicion and complexity of cases.
Pathophysiology & Mechanisms
Alcohol metabolism and neurochemical changes.
Differential diagnosis: Conditions that mimic alcohol withdrawal.
Prehospital & EMS Considerations
Role of EMS in triage and initial management.
Use of sobering centers vs. ED transport.
Prehospital administration of benzodiazepines (IM midazolam).
History & Risk Assessment
Key questions to assess risk for alcohol withdrawal syndrome.
Importance of patient history, medication use, and comorbidities.
Discussion on patient honesty and rapport.
Physical Exam & Scoring Systems
DSM-5 criteria for alcohol withdrawal.
Use of CIWA-AR, BAWS, and PAWSS scoring systems.
Importance of objective measurement for monitoring and disposition.
Complications & Special Presentations
Complicated alcohol withdrawal: Hallucinosis, seizures, delirium tremens.
Diagnostic workup: Labs, imaging, and co-ingestions.
Special populations: End-stage liver disease, pregnancy, intubated patients.
Treatment Strategies
Mainstay: Benzodiazepines (types, dosing, and protocols).
Phenobarbital: Indications, dosing, and evidence.
Adjunctive therapies: Thiamine, glucose, magnesium.
Alternative/adjunct medications: Gabapentin, ketamine, dexmedetomidine, baclofen.
Clinical Pearls & Practice Changes
Early, aggressive therapy to prevent complications.
Symptom-based vs. fixed-schedule treatment.
Gabapentin as an alternative or adjunct.
Anti-craving medications for relapse prevention.
Disposition & Protocols
Use of scoring systems for safe discharge, observation, or admission.
Importance of protocolized approaches and community resources.
Summary & Take-Home Points
Five key practice-changing points.
Clinical pathway.

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Alcohol Withdrawal

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