Alcohol Withdrawal in the Field
Objective: Tell alcohol withdrawal apart from intoxication. Treat withdrawal seizures with the benzodiazepine your protocol names. Do not leave delirium tremens where you found the patient.
Why this matters
A person may stop drinking in jail yesterday and seize today. That is withdrawal, not a first seizure with no story. Withdrawal seizures are emergencies. Delirium tremens is the late, dangerous form of withdrawal. Do not leave it where you found the patient.
- Ask when they last drank, how much they usually drink, and whether they have had delirium tremens or withdrawal seizures before.
- Check sugar first. Low sugar can look like almost anything.
- If your protocol includes a benzodiazepine, that is the drug class for a withdrawal seizure. Do not give phenytoin, a seizure drug used for other causes, for this on scene.
Clinical sequence
- Ask the last drink, the usual amount, and any history of delirium tremens or withdrawal seizures.
- Check sugar before you decide this is only alcohol.
- If they are seizing from withdrawal, use the benzodiazepine your protocol names. Do not give phenytoin for a withdrawal seizure.
- If this is delirium tremens, they may hallucinate, be severely confused, have a fever, and have a fast heart rate. Cool them, protect the airway, and transport. Do not leave them where you found them.
Teaching points
- Intoxication means they are still drunk. Withdrawal starts hours after the last drink. Early signs are tremor, sweat, a fast heart rate, high blood pressure, and anxiety. Seizures can follow. Delirium tremens comes later. They may hallucinate, be severely confused, and have vital signs that will not settle.
- A seizure in a person who drinks heavily is withdrawal until you have a better explanation. Still check sugar. Still look for injury.
- Delirium tremens can kill. Cool them. Give a benzodiazepine if your protocol allows it. Protect the airway and transport. Do not treat a hot, very ill patient as a psychiatric hold in a hallway.
- CIWA-Ar is a hospital score. The Clinical Institute Withdrawal Assessment for Alcohol does not clear a patient in the field. Do not use it as a reason to leave them.
Common errors
- Letting someone “sleep it off” when they have delirium tremens.
- Skipping the sugar check.
- Treating a withdrawal seizure as a reason to refuse transport.
Practice
One-minute check
The last drink was 36 hours ago. They are seizing now. The sugar is 92. Name the drug class and the destination.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; your protocol still decides care
- ASAM Alcohol Withdrawal Management Guideline — benzodiazepines are first-line for withdrawal seizures/DTs — hospital scoring is not a field clearance
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.