Alcohol Withdrawal and Delirium Tremens

Mental Health · Substance Use / Withdrawal·Updated 2026-10-28

What it is

Chronic alcohol use enhances the inhibitory neurotransmitter GABA and blocks the excitatory neurotransmitter glutamate, and the brain adapts by reducing GABA activity and increasing glutamate activity. When drinking stops, this unopposed excitation produces autonomic hyperactivity, seizures and delirium tremens (DTs). Benzodiazepines replace alcohol's GABA effect, which is why they are first-line treatment.

What the NCLEX focuses on

Early signs: tremor, anxiety, insomnia, sweating, nausea, tachycardia and hypertension, beginning 6 to 24 hours after the last drink.
Withdrawal seizures are generalized tonic-clonic and occur 6 to 48 hours after the last drink.
DTs: fever, severe tachycardia and hypertension, diaphoresis, fluctuating disorientation, and visual or tactile hallucinations (insects on the wall); a medical emergency.
The CIWA-Ar scale scores withdrawal severity and guides symptom-triggered benzodiazepine doses; lorazepam or oxazepam is preferred with liver disease or in older adults.
Give thiamine before any glucose-containing fluid to prevent Wernicke encephalopathy: confusion, ataxia and abnormal eye movements.
Expect low magnesium, potassium, phosphate and glucose; correct them because they worsen dysrhythmias and lower the seizure threshold.
Opioid withdrawal (yawning, rhinorrhea, lacrimation, dilated pupils, gooseflesh) is distressing but rarely life-threatening; alcohol and benzodiazepine withdrawal are life-threatening.

Priority nursing actions

Assess airway, vital signs and level of consciousness, and ask the time of the last drink.
Start seizure and fall precautions.
Give the prescribed benzodiazepine according to the CIWA-Ar score.
Give thiamine, then glucose, fluids and electrolyte replacement as prescribed.
Place the client in a quiet, well-lit room near the nurses' station and reorient often.
Reassess the CIWA-Ar score and vital signs per protocol, and report fever or hallucinations at once.

Numbers to know

Item	Timing or value	Why it matters
Early withdrawal	6 to 24 hours after last drink	Treat early to prevent progression
Withdrawal seizures	6 to 48 hours	Seizure precautions from admission
Delirium tremens	48 to 96 hours	Fever, hallucinations, autonomic instability
CIWA-Ar score	Below 10 mild; 10 to 18 moderate; 19 or higher severe	Guides benzodiazepine dosing
Magnesium	1.5 to 2.5 mEq/L (0.75 to 1.25 mmol/L)	Low magnesium lowers the seizure threshold
Thiamine	Before any glucose	Prevents Wernicke encephalopathy

Common exam traps

Choosing to start IV dextrose before thiamine: wrong because glucose without thiamine precipitates Wernicke encephalopathy.
Choosing to wait for hallucinations before medicating: wrong because benzodiazepines given by CIWA-Ar score prevent seizures and DTs.
Choosing a darkened room: wrong because shadows increase illusions and hallucinations; keep the room quiet and well lit.
Choosing an antipsychotic alone for DTs: wrong because it lowers the seizure threshold and does not treat withdrawal; benzodiazepines are first-line.
Choosing to label agitation and insects on the wall at 48 hours as a panic attack: wrong because the timing and autonomic signs indicate DTs.

What to teach

Never stop heavy drinking abruptly without medical supervision because of seizure risk.
Disulfiram: avoid all alcohol, including mouthwash, cough syrups, sauces and aftershave; a reaction remains possible for up to 14 days after the last dose.
Naltrexone and acamprosate reduce cravings; combine them with counseling and mutual-help groups such as Alcoholics Anonymous.
Eat regular meals and take the prescribed thiamine.

Try 2 NCLEX-style questions on this topic

From the NCLEXPace question bank. Pick your answers, then check them inside NCLEXPace.

Question 1 · QID C22600F4

A nurse is triaging two clients with different substance use histories. For each finding, indicate whether it is more consistent with alcohol withdrawal or opioid withdrawal.

For each finding in a client with a suspected substance use issue, indicate whether it is more consistent with alcohol withdrawal or opioid withdrawal.

	Alcohol withdrawal	Opioid withdrawal
Visual hallucinations of insects and marked autonomic hyperactivity at 72 hours
Yawning, lacrimation, rhinorrhea, and muscle aches after abrupt discontinuation
Diarrhea, dilated pupils, and gooseflesh 8 hours after last use
New-onset seizure 24 hours after the last drink

Question 2 · QID 6B23C3C4

A client who drinks heavily was admitted 48 hours ago after a fall and has not had any alcohol since admission. The client is now agitated, febrile, tachycardic, hypertensive, and reports seeing insects on the wall. Which condition is the client most likely developing?

Select the best answer.

A. Acute manic episode
B. A panic attack
C. Delirium tremens
D. Serotonin syndrome

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Sources

The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. J Addict Med. 2020;14(3S Suppl 1):1-72.
Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Fluid, Electrolyte, and Acid-Base Imbalances.
Halter MJ. Varcarolis' Foundations of Psychiatric-Mental Health Nursing: A Clinical Approach. 9th ed. Elsevier; 2022.

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