Alcohol withdrawal at the IMT (Internal Medicine Training) clinical station is answered by deciding who needs a bed, running a symptom-triggered benzodiazepine regimen, and treating for Wernicke's encephalopathy before it is proven. According to NICE CG100, people in acute withdrawal who have, or are at high risk of, withdrawal seizures or delirium tremens should be offered admission for medically assisted withdrawal.

Key takeaways

  • NICE CG100 admits anyone in acute alcohol withdrawal who has, or is at high risk of, withdrawal seizures or delirium tremens, and uses a lower admission threshold for frail, cognitively impaired, comorbid or unsupported patients.
  • In hospital, drug treatment follows a symptom-triggered regimen, with a tool such as CIWA-Ar used as an adjunct to clinical judgement.
  • First-line drugs are a benzodiazepine or carbamazepine; clomethiazole is an inpatient-only alternative used with caution.
  • Delirium tremens is treated with oral lorazepam first line, then parenteral lorazepam or haloperidol if symptoms persist or oral medication is declined.
  • Withdrawal seizures get a quick-acting benzodiazepine such as lorazepam; NICE says do not offer phenytoin.
  • Suspected Wernicke's encephalopathy gets parenteral thiamine for a minimum of 5 days unless the diagnosis is excluded, followed by oral thiamine.

How do you recognise alcohol withdrawal in the scenario?

Alcohol withdrawal in the station is a dependent drinker who stopped 12 to 72 hours ago and is now tremulous, sweating, tachycardic, anxious and possibly hallucinating or fitting. The scenario is usually a surgical or orthopaedic admission where nobody asked about alcohol on clerking.

NICE CG100 asks for immediate assessment on admission by someone skilled in withdrawal, and warns that a sudden reduction in intake can cause severe withdrawal in dependent drinkers. Say that you would take a units-per-day history from the patient and a collateral source.

What does the A to E assessment and first hour look like?

The first hour of alcohol withdrawal is an A to E assessment that looks for the complications hiding behind the tremor: hypoglycaemia, head injury, seizure, sepsis, gastrointestinal bleeding and decompensated liver disease. Withdrawal is a diagnosis of exclusion in a confused drinker.

  • Airway and breathing: protect the airway during or after a seizure, oxygen to target
  • Circulation: fluids for dehydration, bloods including glucose, electrolytes, magnesium, phosphate, liver function, clotting and a full blood count
  • Disability: glucose at the bedside, GCS, pupils, and a low threshold for CT head in any drinker with confusion or a fall
  • Exposure: temperature, signs of chronic liver disease, injuries, and a search for infection
  • Prescribe: a symptom-triggered benzodiazepine regimen, parenteral thiamine, and a CIWA-Ar or equivalent chart started now

Which investigations matter in alcohol withdrawal?

The investigations in alcohol withdrawal are aimed at the mimics and the consequences: glucose, urea and electrolytes, magnesium, phosphate, liver function tests, clotting, full blood count, blood cultures if febrile, an ECG, and imaging of the head if there is any doubt about a subdural haematoma.

The BSG/BASL decompensated cirrhosis bundle adds that a patient with ongoing alcohol intake and cirrhosis needs intravenous Pabrinex or thiamine, a CIWA or GMAWS score, and monitoring for refeeding syndrome. If the patient has decompensated liver disease, NICE CG100 asks for advice from someone experienced in liver disease.

What is the named tool and what are its thresholds?

The named tool in alcohol withdrawal is the Clinical Institute Withdrawal Assessment for Alcohol, revised, or CIWA-Ar, a validated 10-item scale that NICE CG100 recommends as an adjunct to clinical judgement for assessing, monitoring and medicating withdrawal. NICE does not publish score cut-offs; they sit in local protocols.

Say that in hospital, or anywhere with 24-hour monitoring, NICE requires a symptom-triggered regimen: the patient is scored regularly and medicated when the score says so, not on a fixed clock. Explain the logic, which is that fixed regimens over-sedate some and under-treat others.

What is the definitive management of alcohol withdrawal?

Definitive management of alcohol withdrawal is a benzodiazepine or carbamazepine given on a symptom-triggered basis, thiamine, treatment of the complications, and a route into alcohol services. NICE CG100 lists clomethiazole as an alternative, inpatient only and with caution.

Delirium tremens

Delirium tremens is treated with oral lorazepam first line, and with parenteral lorazepam or haloperidol if symptoms persist or oral medication is declined, according to NICE CG100. If delirium tremens develops during treatment, the withdrawal regimen itself must be reviewed.

Withdrawal seizures

Withdrawal seizures are treated with a quick-acting benzodiazepine such as lorazepam to reduce the chance of further seizures. NICE says plainly: do not offer phenytoin for alcohol withdrawal seizures. A seizure during treatment means the regimen was inadequate and needs review.

Wernicke's encephalopathy

Wernicke's encephalopathy is treated on suspicion with parenteral thiamine for a minimum of 5 days unless excluded, then oral thiamine, with doses toward the upper end of the BNF range. NICE also asks for prophylactic parenteral thiamine in malnourished or decompensated drinkers who attend the emergency department or are admitted.

When and to whom do you escalate alcohol withdrawal?

Escalate alcohol withdrawal to the medical registrar when the score keeps climbing despite treatment, to critical care for delirium tremens that is not controlled with oral or parenteral lorazepam, and to the liver team for anyone with decompensated cirrhosis. The alcohol care team and psychiatry liaison are part of the plan from day one, not at discharge.

How do you hand over alcohol withdrawal in one minute?

The alcohol withdrawal handover gives the score trend and the last dose time. Situation: a 55 year old admitted with a fractured wrist, now 36 hours from his last drink, CIWA-Ar rising from 8 to 17 over four hours. Background: a bottle of spirits daily, one previous withdrawal seizure. Assessment: uncomplicated withdrawal so far, glucose normal, no head injury, parenteral thiamine started. Recommendation: symptom-triggered lorazepam per protocol, hourly scoring, review if the score exceeds the local threshold or he seizes, and please ask the alcohol care team to see him tomorrow.

What does the panel listen for in an alcohol withdrawal answer?

The panel listens for the admission decision made on seizure and delirium tremens risk, the phrase symptom-triggered, thiamine given before glucose-containing fluids, and the phenytoin sentence. In practice they also listen for whether you ask about alcohol at all, since the scenario is written so that a candidate who skips the social history misses the diagnosis. The internalmedicineinterview bank of 361 questions with AI-marked spoken practice rehearses that opening.

What are the common mistakes in an alcohol withdrawal station?

  • A fixed-dose regimen on a monitored ward where NICE requires symptom-triggered treatment
  • Phenytoin for a withdrawal seizure
  • Oral thiamine alone in a malnourished drinker who is confused
  • Assuming confusion is withdrawal without a glucose, a temperature and a look at the head
  • Discharging a dependent drinker with advice to stop, when NICE says a sudden reduction can itself cause severe withdrawal

How this comes up at the IMT interview

Alcohol withdrawal maps onto the IMT clinical station as a safety scenario. Investigations and diagnosis is the exclusion of hypoglycaemia, sepsis, bleeding and head injury; management is the symptom-triggered regimen, thiamine and the treatment of delirium tremens and seizures; communication is the non-judgemental alcohol history and the conversation about services. The handover minute is where the score, the last dose and the review trigger are said with times.