SICU

Alcohol Withdrawal Syndrome

Alcohol Withdrawal Syndrome overview including symptom spectrum, CIWA assessment, risk factors for AWD, and treatment principles for surgical ICU patients.

Source: Alcohol Withdrawal Syndrome | SurgCritCare
Status: review pending
Updated: 5/29/2026

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Alcohol Use Disorder (AUD) is prevalent in trauma patients.* Recognizing the risk and early signs of alcohol withdrawal syndrome (AWS) is critical in the SICU.

The spectrum of withdrawal symptoms ranges from mild to severe and life-threatening. The possible lethal sequela of AWS has resulted in the creation of AWS treatment protocols in most hospitals.

Symptom Spectrum

Anxiety • Headache • Insomnia

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Minor Symptoms (Early AWS)

Anxiety
Headache
Insomnia
GI symptoms: nausea, cramping, pain

Advanced Symptoms (6–24 hours)

Visual or auditory hallucinations
Seizures

Severe Symptoms (Alcohol Withdrawal Delirium / Delirium Tremens)

Alcohol Withdrawal Delirium (AWD) — a. k. a. delirium tremens
Features: fever, tachycardia, agitation, diaphoresis, hallucinations, disorientation, hypertension

Patients may develop AWD between 3–8 days after alcohol cessation.*

Incidence:* 3–5% of all patients with AWS progress to AWD.

Although the incidence of AWD is relatively low, its lethal nature requires early identification and prevention for at-risk patients.

CIWA Assessment

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a validated tool that assesses the severity of withdrawal symptoms.

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The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a validated tool that assesses the severity of withdrawal symptoms.

Key domains assessed by CIWA:

Nausea / vomiting
Tremor
Paroxysmal sweats
Anxiety
Agitation
Tactile disturbances
Visual disturbances
Auditory disturbances
Headache
Orientation / clouding of sensorium

CIWA-Ar (revised) scale: Score < 8 = mild; 8–15 = moderate; > 15 = severe

Institution-specific CIWA order sets and protocols should be followed.* Refer to EPIC or your institutional order set.

Prevention

"An ounce of prevention is worth a pound of cure." — Benjamin Franklin, 1736

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"An ounce of prevention is worth a pound of cure." — Benjamin Franklin, 1736

History & Physical — Key Questions for AUD Screening

Last alcohol consumption
Number of drinks per week
History of binge consumption
Previous hospitalizations for alcohol-related issues:
Toxicity
Pancreatitis
Liver dysfunction / sequelae of cirrhosis
Frequent ED visits with positive ETOH screens

Early Interventions for At-Risk Patients

Early initiation of CIWA protocols
Thiamine supplementation (IV or IM) → Treats/prevents Wernicke's encephalopathy
Multivitamin replacement
Electrolyte correction
Assessment for malnutrition secondary to AUD

Treatment

Historically, mainstay treatment was benzodiazepines and barbiturates.

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Historically, mainstay treatment was benzodiazepines and barbiturates.

These are being augmented by newer agents, including:

Gamma-aminobutyric (GABAergic) agents
Anti-epileptic drugs
Alpha-2 adrenergic receptor agonists

For more information on novel approaches, see: "Novel Algorithms for the Prophylaxis and Management of Alcohol Withdrawal Syndromes — Beyond Benzodiazepines" by Maldonado (Journal of Hospital Medicine).

Do NOT prescribe specific medication doses or protocols without attending guidance and your institution's current AWS order set.*

Important Notes

This content is adapted from SurgCritCare. org • Treatment protocols (benzodiazepine dosing, adjuncts, CIWA frequency) are...

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This content is adapted from SurgCritCare. org
Treatment protocols (benzodiazepine dosing, adjuncts, CIWA frequency) are institution-specific
Always follow your institution's AWS order set in EPIC or your EHR
Thiamine before glucose when Wernicke's is possible

Adapted from SurgCritCare. org. Verify treatment protocols against current institutional AWS order set and attending guidance.*

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