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Alcohol Withdrawal Syndrome        
The Stages of Alcohol Withdrawal Syndrome

• Stages 1: Onset 6-8 hours
  SX: agitation, anxiety, tachycardia, hypertension, N & V, anorexia, headache, insomnia, craving for alcohol, diaphoresis, tremor
• Stages 2: Onset 24 hours (may be delayed up to 6 days)
  SX: hallucinations (auditory or visual, tacile, olfactory or mixed), illusions, disordered perception, autonomic hyperactivity of stage 1 continues.
• Stages 3:  Onset 7-48 hours
  SX: grand mal seizures; 3-4% of untread patiens progress to stage 3; more than 50% have multiple seizures; >30% have Delirium Tremens if untreated.
• Stages 4:  Onset 3-5 or more days
  SX:  Delerium tremens DT, (global confusion, autonomic hyperactivity, hallucinations); 5-6% of patients progress to stage 4; in 15% of these, DT resolve in <24 hours; iin 80%, DT usually resolve in <3 days.

Drug regimens for managing Alcohol Withdrawal Syndrome

For mild to moderate symptoms:

• Chlordiazepoxide/Librium 25-100 mg q6h PO, then taper down dose (Half life 5-15 h)
• Oxazepam/Serax 15-30 mg q6h PO, then taper down dose (Half life 5-10 h)
• Diazepam/Valium 5-20 mg q6h PO, then taper down dose (Half life >10 h)
• Lorazepam/Ativan 1-2 mg q4-6h PO, then taper down dose (Half life 5-10 h)

For severe symptoms:

• Lorazepam/Ativan 1-4 or more mg q2-4h IV or by IV infusion.(Half life >10h)
• Midazolam/Versed 1-5 or more mg q2-4h IV or by IV infusion (Half life 1-4h)

Adjunctive therapy:

• Thiamine, fluid & electrolytes (esp. Magnesium), psychiatric evaluatio, management of coexisting medical/surgical conditions, nutrition, referral to chemical dependency clinic or rehabilitation program when stable.
• Seizure Rx: Lorazepam/Ativan or Diazepam/Valium IV; Dilantin & others as indicated.
• Hypertension Rx: Beta-blockers or Clonidine as indicated.
• GI bleeding Rx as indicated.

Ref:
J of Critical Illness May 1998, Vol 13. No.5 - Richard W. Carlson, etc.