Alcohol Withdrawal Syndrome Guidelines

Below are the updated AWS guidelines for the EHC emergency department. Note that chlordiazepoxide/librium is favored in all patients who are able to take oral medications and who are not severely agitated (RASS ≥3).  The goal of therapy is a calm to drowsy patient (RASS 0 to -1) regardless of HR/BP.  If a patient remains tachycardic despite adequate sedation, strongly consider concurrent or alternative pathology, eg. sepsis. 

EHC AWS algorithm 11-28


In addition, use of the non-benzodiazepine (BZD) adjuncts such as dexmedetomidine/precedex is not advised unless the patient is refractory to BZD and barbiturate therapy.  The refractory AWS pathway (pg2) outlines a suggested strategy for those patients in whom adequate control cannot be obtained despite diazepam 200mg and phenobarbital 390mg.  In these patients the overall goal is to avoid intubation unless absolutely necessary.  The suggested non-BZD adjunct in this scenario is ketamine, which is more strongly supported by evidence.

The goal of management in AWS is to determine the dosage of benzodiazepine that is required to control a patient (calm/alert to slightly drowsy or RASS 0 to -1) for at least 1hr from last administration of medication.

In addition to admission to a unit capable of appropriate level of care, evaluate patients for co-morbid conditions such as trauma, sepsis, pancreatitis, DKA/AKA,  etc.  Strongly consider the supplementation of multivitamin/thiamine/folate to patients at risk for malnutrition. 

These guidelines were adopted from Bellevue’s AWS protocol  and updated with the assistance of our EHC/MSSM toxicologists Alex Manini, Rachel Shively and Beth Ginsburg.  Any questions or concerns please feel free to contact me at