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Ordinarily, the excitatory (glutamate) and inhibitory (GABA) neurotransmitters are in a state of homeostasis [Figure 1a]. Alcohol facilitates GABA action, causing decreased CNS excitability [Figure 1b]. In the long-term, it causes a decrease in the number of GABA receptors (down regulation). This results in the requirement of increasingly larger doses of ethanol to achieve the same euphoric effect, a phenomenon known as tolerance. Alcohol acts as an N-methyl-D-aspartate (NMDA) receptor antagonist, thereby reducing the CNS excitatory tone. Chronic use of alcohol leads to an increase in the number of NMDA receptors (up regulation) and production of more glutamate to maintain CNS homeostasis [Figure 1c].

SBIRT is used most frequently in emergency settings with patients who present with acute intoxication and alcohol-related injuries and has not been studied specifically in individuals with alcohol withdrawal. Meta-analyses of these interventions in the ED show a small reduction in drinking in low to moderate alcohol users with many individual studies failing to show significant reduction in alcohol consumption. Interventions with follow-up contact were not superior to single interactions. There is limited evidence to support a small reduction in subsequent instances of alcohol-related injuries.84,85 More research is needed to establish effective interventions for individuals presenting to the ED with complications of alcohol use. ED clinicians are responsible for risk-stratifying patients with alcohol withdrawal syndrome under time and resource constraints, and must reliably identify those who are safe for outpatient management versus those who require more intensive levels of care [7].

What is an alcohol withdrawal seizure?

All patients with seizures or DT should have immediate intravenous access for administration of drugs and fluids. Adequate sedation should be provided to calm the patient as early as possible and physical restraints may be used as required in order to prevent injuries due to agitation. Adequate nutrition must be ensured with care to prevent aspiration in over-sedated patients.

  • Patients who experience harms from alcohol and other substance use often seek care in the emergency department (ED) [1, 2].
  • Symptoms outside of the anticipated withdrawal period or resumption of alcohol use also warrants referral to an addiction specialist or inpatient treatment program.
  • Person ascertaining outcomes, primary outcomes, secondary and tertiary outcomes, adverse events.
  • Ethanol also binds to glutamate, which is one of the excitatory amino acids in the central nervous system.

Even though alcohol use may trigger seizures, 65% of interviewed subjects had consumed alcohol within the last 12 months and every third patient had consumed alcohol within the last 7 days. Our results are in line with previous population-based study findings from Canada reporting a 12-month prevalence of alcohol use in patients with epilepsy of 57.6% (20). Regarding chronic heavy alcohol consumption, our cohort of patients had used alcohol far more responsibly than the general adult German population.

Assessment of Alcohol Withdrawal

An alternative adjunctive medication useful in patients with refractory DT is haloperidol given in doses of 0.5-5 mg by intramuscular route every min[29] or 2-20 mg/h[34] while continuing to give diazepam mg every 1-2 h. Newer antipsychotics like risperidone (1-5 mg/day) or olanzapine (5-10 mg/day) may have a better why does alcohol withdrawal cause seizures safety profile than haloperidol (2, 5-10 mg/day)[7] and are preferred as adjuncts to benzodiazepine treatment. In these cases, we recommend that patients should be started immediately on a SML dose regimen, while monitoring the withdrawal severity (CIWA-Ar ratings) and clinical signs of tachycardia and hypertension.

The evidence for use of NBACs to target heavy drinking in outpatient settings is stronger than the evidence for AWS, with most evidence being in support of topiramate and gabapentin. Moderately severe AWS causes moderate anxiety, sweating, insomnia, and mild tremor. Those with severe AWS experience severe anxiety and moderate to severe tremor, but they do not have confusion, hallucinations, or seizures.

What Should I Do After an Alcohol-Related Seizure?

A person that has experienced an alcoholic seizure is at a higher risk for developing epilepsy and other seizure disorders. Experiencing an alcohol-related seizure indicates that a person is suffering from extreme withdrawal symptoms. Some literature recommends checking an alcohol level at the time of onset of symptoms as symptomatic patients while still having a positive alcohol level with symptoms of autonomic dysfunction/withdrawal will have a higher morbidity/mortality, and their short-term prognosis can be poor. Long-term treatment of AUD should begin concurrently with the management of AWS.8 Successful long-term treatment includes evidence-based community resources and pharmacotherapy.

  • Carbamazepine and gabapentin appear to be the most promising adjunctive treatments for AWS, and they may be useful as monotherapy in select cases, especially in outpatient settings and for the treatment of mild-to-moderate low-risk patients with the AWS.
  • For severe AWS, a meta-analysis of randomized placebo-controlled studies provides clear evidence that benzodiazepines reduce the incidence of alcohol withdrawal seizures (–7.7 seizures per 100 patients) and alcohol withdrawal delirium (–4.9 cases per 100 patients) [15].
  • Logistic regression analyses were used to calculate odds ratios with 95% confidence intervals as estimates for variables independently predicting alcohol use and the occurrence of alcohol-related seizures within the last 12 months.
  • However, it should be noted that the mean dose of phenobarbital used in this latter study was 260mg versus the 10mg/kg dose of phenobarbital used in the original study.

Alcohol withdrawal seizures may begin within hours to days of stopping alcohol use or starting an alcohol detox. The timeframe will be different for everyone, but seizures will normally start within the first 72 hours. An alcohol withdrawal seizure may feel like a loss of consciousness which you are slow to wake up from. If you are conscious during an alcohol withdrawal seizure, you may experience repetitive, uncontrolled movements of part or all of your body. Prior to the seizure, you may also experience an “aura,” consisting of an unusual visual change, smell, taste, or sound caused by abnormal brain activity.


A typical alcohol withdrawal seizure is a tonic-clonic seizure (also called a grand-mal seizure).[4] This episode involves a loss of consciousness accompanied by violent muscle spasms. But some people can experience smaller episodes that don’t seem like full-body seizures. Emergency providers should be familiar with emergent as well as pharmacologic and behavioral interventions to address withdrawal and facilitate alcohol cessation upon discharge. This review summarizes literature regarding the identification and management of alcohol withdrawal in the ED as well as techniques for facilitating transitions of care for individuals experiencing alcohol withdrawal. The deliberate withdrawal from alcohol by a dependent drinker under the supervision of medical staff. It can be carried out at home, in the community or in a hospital or other inpatient facility.

Some patients present with a chief complaint and symptoms that direct providers immediately to the etiology of alcohol withdrawal. Furthermore, a number of patients present to the emergency department for complaints not at all related to alcohol withdrawal and yet proceed to develop symptoms of acute alcohol withdrawal during their stay. Given the rapidly changing landscape of alcohol-related ED visits during the COVID-19 pandemic, and the potential for new treatment strategies to quickly emerge, there is an urgent need in the near future for a full systematic review and evidence synthesis.

Benzodiazepines are the most evidence-based treatment for alcohol withdrawal in the ED. Pharmacotherapies that have demonstrated benefit for treatment of alcohol withdrawal in other inpatient and outpatient settings should be evaluated in the ED setting before routine use. With long-term heavy drinking, alcoholic patients develop a ‘protracted abstinence syndrome’ in which they need at least some alcohol to attempt to feel a ‘normal’ mood, reward, and stress response [5].