In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the November 2025 Emergency Medicine Practice article, Diagnosis and Management of Emergency Department Patients With Alcohol Withdrawal Syndrome

1. Epidemiology & Background

• Rising ED visits related to alcohol use.
• Mortality rates and spectrum of patient presentations.
• Importance of high suspicion and complexity of cases.
• Pathophysiology & Mechanisms
• Alcohol metabolism and neurochemical changes.
• Differential diagnosis: Conditions that mimic alcohol withdrawal.
• Prehospital & EMS Considerations
• Role of EMS in triage and initial management.
• Use of sobering centers vs. ED transport.
• Prehospital administration of benzodiazepines (IM midazolam).
• History & Risk Assessment
• Key questions to assess risk for alcohol withdrawal syndrome.
• Importance of patient history, medication use, and comorbidities.
• Discussion on patient honesty and rapport.
• Physical Exam & Scoring Systems
• DSM-5 criteria for alcohol withdrawal.
• Use of CIWA-AR, BAWS, and PAWSS scoring systems.
• Importance of objective measurement for monitoring and disposition.
• Complications & Special Presentations
• Complicated alcohol withdrawal: Hallucinosis, seizures, delirium tremens.
• Diagnostic workup: Labs, imaging, and co-ingestions.
• Special populations: End-stage liver disease, pregnancy, intubated patients.
• Treatment Strategies
• Mainstay: Benzodiazepines (types, dosing, and protocols).
• Phenobarbital: Indications, dosing, and evidence.
• Adjunctive therapies: Thiamine, glucose, magnesium.
• Alternative/adjunct medications: Gabapentin, ketamine, dexmedetomidine, baclofen.
• Clinical Pearls & Practice Changes
• Early, aggressive therapy to prevent complications.
• Symptom-based vs. fixed-schedule treatment.
• Gabapentin as an alternative or adjunct.
• Anti-craving medications for relapse prevention.
• Disposition & Protocols
• Use of scoring systems for safe discharge, observation, or admission.
• Importance of protocolized approaches and community resources.
• Summary & Take-Home Points
• Five key practice-changing points.
• Clinical pathway.

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