Alcohol Withdrawal

Alcohol Withdrawal Syndrome (AWS) requires high clinical suspicion in the emergency department, as its presentation—tachycardia, hypertension, and delirium—frequently mimics sepsis, head trauma, and drug intoxication. Effective management relies on early, aggressive, front-loaded therapy to prevent progression to severe complications like delirium tremens. While benzodiazepines remain the standard of care, phenobarbital has emerged as a potent, long-acting alternative, particularly useful during medication shortages or for stabilizing patients before inpatient admission. Symptom-based dosing protocols, guided by the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar), outperform fixed-schedule regimens by tailoring medication to individual patient needs. Additionally, gabapentin serves as a valuable adjunct for outpatient management, potentially reducing relapse rates and total benzodiazepine requirements. Clinicians should prioritize thiamine administration to prevent Wernicke’s encephalopathy and maintain a low threshold for investigating co-ingestions or underlying metabolic derangements in this complex, high-risk population.