Quick Chart

Alcohol withdrawal syndrome is a set of clinical features that can occur when a person reduces or abruptly stops alcohol consumption after long periods of use.

The pathophysiology of alcohol withdrawal is incompletely understood. Sudden cessation of or a significant reduction in alcohol consumption triggers an acute neurotransmitter imbalance with rapid decline in inhibitory GABA activity and increased excitatory glutamate/NMDA activity, resulting in overall CNS hyperactivity and reduced threshold for seizures.

Symptoms of alcohol withdrawal typically manifest when a person stops or decreases their alcohol consumption after a prolonged period of drinking. Mild symptoms often begin to emerge within a few hours of the last alcoholic beverage.

Alcohol withdrawal can be dangerous due to its potential to cause severe and potentially life-threatening symptoms, known as delirium tremens (DTs)

 Clinical Presentation

Mild withdrawal typically occurs within 24 hours of the last drink and is characterized by the following:

  • Tremors
  • Insomnia
  • Anxiety
  • Hyperreflexia
  • Diaphoresis
  • GI upset

Moderate withdrawal usually occurs 24-36 hours after the cessation of alcohol intake and includes the following:

  • Intense anxiety
  • Tremors
  • Insomnia

Severe withdrawal usually occurs more than 48 hours after a cessation or decrease in alcohol consumption and is characterized by the following:

  • Profound alteration of sensory nervous system:
    • Disorientation
    • Agitation
    • Hallucinations
  • Severe autonomic hyperactivity:
    • Tremulousness
    • Tachycardia
    • Tachypnea
    • Hyperthermia
    • Diaphoresis

Seizures in patients experiencing alcohol withdrawal

Alcohol-withdrawal seizures are usually:

  • Brief (no longer than 30 to 60 seconds)
  • Generalised
  • Seen in people with alcohol dependence with a long history of high alcohol intake
  • Evident early in withdrawal

Tachycardia, sweating and agitation after a seizure support a diagnosis of a withdrawal seizure; a calm, drowsy postictal patient is likely to have a comorbid seizure disorder.

Delirium in alcohol withdrawal

In patients with alcohol dependence, common risk factors for delirium are acquired brain injury, cognitive impairment; including dementia, and acute medical or surgical illness. Delirium tremens (DT's) are rarely seen, probably because of the widespread use of benzodiazepine treatment to manage alcohol withdrawal.

DT's are the most severe manifestation of alcohol withdrawal and are characterised by:

  • Generalised tremors
  • Diaphoresis
  • Fluctuation levels of agitation, hallucinations (usually tactile)
  • Disorientation and impaired attention

Delirium tremens is usually identified after 48 to 72 hours of more severe alcohol withdrawal in the setting of recent acute illness or surgery. Delirium tremens is a medical emergency that always requires hospitalisation and, if inadequately treated, carries mortality risk, mainly from heart failure.

 Exclusion Criteria
Exclusion Criteria
 Risk Assessment
Alcohol withdrawal risk stratification
Orientation0 – Oriented

The patient is fully oriented in time, place and person

1 - DisorientedDisoriented but cooperative
2 - UncooperativeDisoriented but uncooperative
Agitation / Anxiety0 - CalmRests normally
1 - AnxiousAppears anxious
2 - PanickyAppears very agitated all the time
Hallucination0 - NoneNo evidence of hallucinations
1 – Can DissuadeDistortions of real objects or hallucinations, but accepted as not real when pointed out
2 – Cant DissuadeBelieves the hallucinations are real and cannot be reassured
Perspiration0 – NilNo abnormal sweating
1 – Moist/WetMild to moderate perspiration
2 - SoakingSoaking sweat
Tremor0 – No TremorNo tremor
1 - With intentional movementsTremor when moving hands and arms
2 – Tremor at restConstant tremor of arms, even at rest
Temperature0 – 37.5ºCTympanic
1 – 37.6ºC – 38.5ºCTympanic
2 - >38.5ºCTympanic

A score of ≥ 1 should be escalated to ED triage for review.

* Hallucination  =  Appearance of totally new objects or perception not related to any new object

Predictors of severe or complicated alcohol withdrawal

  • A history of moderate to severe alcohol withdrawal, especially multiple episodes
  • Current acute medical or surgical illness
  • Current acute mental illness, such as anxiety [NB1]
  • Severe comorbidity that might be destabilised (e.g. chronic liver disease, chronic obstructive pulmonary disease), seizure disorder or suspected lowered seizure threshold
  • History of memory blackouts (acute memory loss during alcohol intoxication)
  • Cognitive impairment
  • Early-morning drinking to alleviate withdrawal symptoms (anxiety, nausea, tremor
  • Use of more than one substance (polysubstance use), particularly benzodiazepines, but also opioids, stimulants
  • In older patients or those with polysubstance use, an intake of more than 8 standard drinks of alcohol per day [NB2]

NB1: Alcohol withdrawal in a person with an anxiety disorder causes escalation in anxiety levels. Many of the signs monitored on an alcohol withdrawal scale are also exacerbated by anxiety (tremor, tachycardia, sweating). The usual duration of the acute alcohol withdrawal phase is 2 to 3 days. Anxiety that persists longer is often misinterpreted as persisting acute withdrawal, leading to prolonged use of the alcohol withdrawal scale and excessive administration of diazepam.

NB2: In other patients, the feature of early-morning drinking to alleviate withdrawal is more relevant than the number of drinks per day.

Primary Care
Intermediate Care
  • As per Primary Care guidelines
Advanced Care
    Critical & Extended Care
    • As per Advanced Care guidelines
     Additional Information

    Providing an alcohol withdrawal risk stratification score to ED triage will assist the hospital identify the need for supportive care. 

    Key Terms & Links
    Extended Care:
    Colour assist:


    Wood, E., Albarqouni, L., Tkachuk, S., Green, C. J., Ahamad, K., Nolan, S., McLean, M., & Klimas, J. (2018, August 28). Will this hospitalized patient develop severe alcohol withdrawal syndrome?: The Rational Clinical Examination Systematic Review. JAMA. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6905615/

    SA Health. Alcohol withdrawal management.

    Nathanael J McKeown, D. (2022, July 13). Withdrawal syndromes clinical presentation. History, Physical Examination. https://emedicine.medscape.com/article/819502-clinical

    Therapeutic Guidelines. (n.d.). https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Addiction+Medicine&topicfile=alcohol-drug-problems&guidelinename=auto&sectionId=c_AMG_Alcohol-withdrawal_topic_11#c_AMG_Alcohol-withdrawal_topic_11 

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