The spectrum and timing (approximate — timing varies)
- Uncomplicated withdrawal (6–12 h): tremor, sweating, anxiety, nausea, tachycardia.
- Withdrawal seizures (~12–48 h): generalised tonic‑clonic.
- Alcoholic hallucinosis (~12–24 h): hallucinations with clear sensorium (distinguishes it from DTs).
- Delirium tremens (~48–72 h): delirium (fluctuating attention/consciousness) + severe autonomic instability + hallucinations + disorientation — mortality if untreated.
The distinction that must be automatic
Hallucinosis ≠ DTs. Hallucinations with intact orientation and attention = hallucinosis. DTs = hallucinations + clouded, fluctuating consciousness + autonomic storm. The clouded sensorium and autonomic instability define the emergency.
Management
Benzodiazepines are first‑line for withdrawal, seizures, and DTs (symptom‑triggered CIWA‑Ar dosing; escalate to ICU for DTs; phenobarbital/adjuncts for benzodiazepine‑resistant cases). Antipsychotics are not used alone (lower seizure threshold; don't treat the GABA deficit). Thiamine (parenteral, before carbohydrate) to prevent/treat Wernicke's; replace electrolytes; supportive care.
Wernicke's encephalopathy 🚩
Thiamine deficiency → acute emergency. Classic triad confusion + ophthalmoplegia + ataxia — but the complete triad is frequently absent, so treat empirically on suspicion. Untreated → Korsakoff's (irreversible anterograde amnesia + confabulation). Any alcohol‑dependent patient with confusion gets thiamine.
Pitfalls
- Labelling confusion "just withdrawal" and missing Wernicke's/another cause.
- Treating withdrawal delirium with an antipsychotic alone.
Pearls
- 🎯 DTs = delirium + autonomic instability, not hallucinations alone.
- 🩺 Don't wait for the full triad — give parenteral thiamine on suspicion of Wernicke's.
Next → The overdose emergency with a specific antidote (Concept 43).