Alcohol withdrawal seizures - Revision history

Danbot: Expand with concise EM-focused content: no phenytoin pearl, anchoring warning, BZD dosing, electrolyte repletion

2026-03-21T01:29:08Z

Expand with concise EM-focused content: no phenytoin pearl, anchoring warning, BZD dosing, electrolyte repletion

← Older revision		Revision as of 01:29, 21 March 2026
Line 1:		Line 1:
	==Background==		==Background==
	*Onset after last drink~~: 6-48h~~		*Generalized tonic-clonic seizures occurring in the context of [[alcohol withdrawal]]
	*Multiple seizures: 60% of patients		*'''Onset:''' 6-48 hours after last drink (peak at 24 hours)
	*~~Progression~~ to [[~~Delerium~~ tremens]]~~: 33% of patients~~		*Multiple seizures occur in ~60% of patients
	*May occur ~~in spectrum~~ or ~~independent~~ of [[~~Alcohol~~ withdrawal]] ~~syndrome~~		*~33% progress to [[delirium tremens]] if untreated
			*May occur as isolated finding or as part of the broader [[alcohol withdrawal]] spectrum
			*'''Key pearl:''' First-time seizure in a chronic alcoholic still requires full workup — do not assume alcohol withdrawal without ruling out other causes

	==Clinical Features==		==Clinical Features==
	*~~Single or multiple brief~~ tonic-clonic seizures ~~in the appropriate time setting for alcohol withdrawal~~<~~ref>Manasco A, Chang S~~, ~~Larriviere J~~, ~~et al. Alcohol withdrawal. Southern Medical Journal. 2012; 105(11~~)~~:607–612.</ref>~~		*Brief, generalized tonic-clonic seizures (usually <5 minutes)
			*Typically self-limited
			*'''Focal seizure features or prolonged seizure suggest an alternative or concurrent etiology''' (intracranial hemorrhage, CNS infection, structural lesion)
			*Post-ictal period may be brief

	==Differential Diagnosis==		==Differential Diagnosis==
Line 13:		Line 18:

	==Evaluation==		==Evaluation==
	*~~Appropriate history with timeline~~		*'''Do not anchor on withdrawal''' — rule out other causes especially in first-time seizures:
	*~~Clinical features~~		**Glucose, BMP (electrolytes, magnesium), CBC
	*~~Elevated~~ CIWA		**CT head: obtain if first seizure, focal findings, prolonged altered mental status, head trauma, or anticoagulation
			**Consider LP if fever or meningeal signs
			*Assess CIWA score to guide withdrawal severity
	{{CIWA score}}		{{CIWA score}}
			*Ethanol level, [[urine toxicology screen]]
			*Magnesium and phosphate levels (commonly depleted in alcoholics)

	==Management==		==Management==
	''~~Don’t use~~ [[~~phenytoin~~]] or [[~~fosphenytoin~~]] to treat seizures caused by drug toxicity or drug withdrawal.<ref>Choosing Wisely. American College of Medical Toxicology and The American Academy of Clinical Toxicology. http://www.choosingwisely.org/clinician-lists/acmt-and-aact-phenytoin-or-fosphenytoin~~-to-treat-~~seizures~~/</ref>~~		*'''Benzodiazepines are first-line''' for both acute seizure treatment and withdrawal prophylaxis:
	''		**[[Lorazepam]] 2-4 mg IV for active seizure
			**[[Diazepam]] 10-20 mg IV for active seizure (faster onset, longer acting)
			*'''Do NOT use phenytoin or fosphenytoin''' for alcohol withdrawal seizures (ineffective and potentially harmful)
			*Replete electrolytes: magnesium (2g IV), thiamine (100-500 mg IV BEFORE glucose), folate
	{{Inpatient management of ETOH withdrawal}}		{{Inpatient management of ETOH withdrawal}}

	==Disposition==		==Disposition==
	*~~Admission~~		*Admit for observation and monitored benzodiazepine protocol
			*ICU if: status epilepticus, refractory seizures, concern for delirium tremens, hemodynamic instability
			*Consider outpatient management only if: isolated seizure, no other concerning features, reliable follow-up, safe discharge plan

	==See Also==		==See Also==
	*[[Alcohol withdrawal]]		*[[Alcohol withdrawal]]
	*[[~~Delerium~~ tremens]]		*[[Delirium tremens]]
	*[[EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal]]
	*[[Seizure]]		*[[Seizure]]
			*[[Status epilepticus]]
	~~==External Links==~~
	*[~~http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator MDCalc - CIWA-AR Calculator~~]

	==References==		==References==
	<references/>		<references/>

	[[Category:Neurology]][[Category:Psychiatry]][[Category:Toxicology]]		[[Category:Neurology]]
			[[Category:Psychiatry]]
			[[Category:Toxicology]]

Teledoc4u: /* Evaluation */

2025-08-01T05:33:49Z

Evaluation

← Older revision		Revision as of 05:33, 1 August 2025
Line 13:		Line 13:

	==Evaluation==		==Evaluation==
			*Appropriate history with timeline
	*Clinical features		*Clinical features
	*Elevated CIWA		*Elevated CIWA

Rossdonaldson1: /* Management */

2020-10-24T09:27:50Z

Management

← Older revision		Revision as of 09:27, 24 October 2020
Line 21:		Line 21:
	''Don’t use [[phenytoin]] or [[fosphenytoin]] to treat seizures caused by drug toxicity or drug withdrawal.<ref>Choosing Wisely. American College of Medical Toxicology and The American Academy of Clinical Toxicology. http://www.choosingwisely.org/clinician-lists/acmt-and-aact-phenytoin-or-fosphenytoin-to-treat-seizures/</ref>		''Don’t use [[phenytoin]] or [[fosphenytoin]] to treat seizures caused by drug toxicity or drug withdrawal.<ref>Choosing Wisely. American College of Medical Toxicology and The American Academy of Clinical Toxicology. http://www.choosingwisely.org/clinician-lists/acmt-and-aact-phenytoin-or-fosphenytoin-to-treat-seizures/</ref>
	''		''
	{{~~Vitamin prophylaxis for~~ ETOH}}		{{Inpatient management of ETOH withdrawal}}

	==Disposition==		==Disposition==

Rossdonaldson1: /* Management */

2020-10-24T09:27:24Z

Management

← Older revision		Revision as of 09:27, 24 October 2020
Line 21:		Line 21:
	''Don’t use [[phenytoin]] or [[fosphenytoin]] to treat seizures caused by drug toxicity or drug withdrawal.<ref>Choosing Wisely. American College of Medical Toxicology and The American Academy of Clinical Toxicology. http://www.choosingwisely.org/clinician-lists/acmt-and-aact-phenytoin-or-fosphenytoin-to-treat-seizures/</ref>		''Don’t use [[phenytoin]] or [[fosphenytoin]] to treat seizures caused by drug toxicity or drug withdrawal.<ref>Choosing Wisely. American College of Medical Toxicology and The American Academy of Clinical Toxicology. http://www.choosingwisely.org/clinician-lists/acmt-and-aact-phenytoin-or-fosphenytoin-to-treat-seizures/</ref>
	''		''
	*Treat with [[Benzodiazepines\|benzos]] (not [[phenytoin]])		{{Vitamin prophylaxis for ETOH}}
	*See [[Alcohol withdrawal#Inpatient Management]]

	==Disposition==		==Disposition==

Rossdonaldson1: /* Management */

2020-10-24T09:21:54Z

Management

← Older revision		Revision as of 09:21, 24 October 2020
Line 19:		Line 19:

	==Management==		==Management==
			''Don’t use [[phenytoin]] or [[fosphenytoin]] to treat seizures caused by drug toxicity or drug withdrawal.<ref>Choosing Wisely. American College of Medical Toxicology and The American Academy of Clinical Toxicology. http://www.choosingwisely.org/clinician-lists/acmt-and-aact-phenytoin-or-fosphenytoin-to-treat-seizures/</ref>
			''
	*Treat with [[Benzodiazepines\|benzos]] (not [[phenytoin]])		*Treat with [[Benzodiazepines\|benzos]] (not [[phenytoin]])
	*See [[Alcohol withdrawal#Inpatient Management]]		*See [[Alcohol withdrawal#Inpatient Management]]

Rossdonaldson1: /* See Also */

2019-08-08T18:34:01Z

Rossdonaldson1: Text replacement - " phenytoin" to " phenytoin"

2016-08-03T22:27:55Z

Text replacement - " phenytoin" to " phenytoin"

← Older revision		Revision as of 22:27, 3 August 2016
Line 19:		Line 19:

	==Management==		==Management==
	*Treat with [[Benzodiazepines\|benzos]] (not phenytoin)		*Treat with [[Benzodiazepines\|benzos]] (not [[phenytoin]])
	*See [[Alcohol withdrawal#Inpatient Management]]		*See [[Alcohol withdrawal#Inpatient Management]]

Neil.m.young: Text replacement - "==Diagnosis==" to "==Evaluation=="

2016-07-23T06:41:23Z

Text replacement - "==Diagnosis==" to "==Evaluation=="

← Older revision		Revision as of 06:41, 23 July 2016
Line 12:		Line 12:
	{{Seizure DDX}}		{{Seizure DDX}}

	==~~Diagnosis~~==		==Evaluation==
	*Clinical features		*Clinical features
	*Elevated CIWA		*Elevated CIWA

Rossdonaldson1: /* Diagnosis */

2016-07-08T12:25:11Z

Diagnosis

← Older revision		Revision as of 12:25, 8 July 2016
Line 15:		Line 15:
	*Clinical features		*Clinical features
	*Elevated CIWA		*Elevated CIWA

			{{CIWA score}}

	==Management==		==Management==

Rossdonaldson1: /* Management */

2016-07-08T11:51:44Z

Management

← Older revision		Revision as of 11:51, 8 July 2016
Line 18:		Line 18:
	==Management==		==Management==
	*Treat with [[Benzodiazepines\|benzos]] (not phenytoin)		*Treat with [[Benzodiazepines\|benzos]] (not phenytoin)
	*See [[Alcohol withdrawal: Inpatient ~~management~~]]		*See [[Alcohol withdrawal#Inpatient Management]]

	==Disposition==		==Disposition==

← Older revision		Revision as of 18:34, 8 August 2019
Line 29:		Line 29:
	*[[Delerium tremens]]		*[[Delerium tremens]]
	*[[EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal]]		*[[EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal]]
			*[[Seizure]]

	==External Links==		==External Links==