Alcohol withdrawal at 36 hours: delirium, capacity and restraint

This is alcohol withdrawal delirium, the severe end of the withdrawal spectrum and effectively delirium tremens. It is not simple withdrawal hallucinosis, because disorientation and clouding of consciousness are present alongside visual hallucinations and autonomic overactivity.

Why the timing fits

• Tremor and autonomic signs begin 6–24 hours after the last drink; hallucinations at 12–24 hours; withdrawal seizures at 12–48 hours; delirium tremens typically at 48–96 hours. At 36 hours he is entering the highest-risk window, and he may deteriorate further over the next two days.

Why the score matters

• A CIWA-Ar score of 18 is in the severe range (above 15) and indicates a high risk of seizures, arrhythmia and death, and warrants symptom-triggered or fixed-dose benzodiazepines with monitoring, not reassurance alone.
• The previous withdrawal seizure is an independent risk factor for further seizures and delirium, and lowers the threshold for pharmacological treatment.

Additional risks

• Temperature 37.8 °C, pulse 116 and BP 158/96 indicate marked sympathetic overactivity; hyperthermia, tachycardia and dehydration can progress to cardiovascular collapse.
• Untreated delirium tremens carries substantial mortality, so this patient needs a monitored bed and frequent observation, not a quiet corner.
• Look for hypoglycaemia, hypokalaemia, hypomagnesaemia, infection and head injury, all of which mimic or aggravate the picture.

Environment and observation

• Move him to a quiet, well-lit cubicle near the nursing station with continuous or 15-minute observation, and a staff member present at all times while he is disoriented.
• Speak calmly, orient him repeatedly to place and time, use short sentences, avoid arguing with the hallucinations, and reduce noise and bright light.

Drug safety

• Thiamine 100 mg intravenously before any glucose-containing fluid, then daily, to prevent Wernicke encephalopathy; give glucose only after thiamine if hypoglycaemia is suspected.
• Benzodiazepines as prescribed (chlordiazepoxide or diazepam), titrated to the CIWA-Ar score, with the score repeated hourly; flumazenil must never be given to these patients.
• Do not use antipsychotics alone to control agitation - they lower the seizure threshold and impair temperature regulation.
• Correct magnesium and potassium, and give intravenous fluids for dehydration.

Physical safety and restraint

• Seizure precautions: padded side rails, suction and oxygen at hand, bed in the lowest position.
• Fall prevention and removal of sharp objects; a close-fitting identification band.
• Physical restraint is not the first response. Attempt de-escalation, family presence, a calm environment and adequate sedation first. If restraint is unavoidable, it requires a written medical order, the least restrictive method, release and circulation checks at least every 15 minutes, fluids and toileting offered, and full documentation of the reason, duration and monitoring. Restraint is never used as punishment or for staff convenience, and never as a substitute for adequate drug treatment.
• Monitor temperature, pulse, blood pressure, respiratory rate, oxygen saturation, fluid balance and level of consciousness, and watch for a rising temperature or falling level of consciousness.

Family Explain that the confusion is caused by withdrawal and is treatable, and that tying him down without treatment would worsen agitation and injury risk.

Assess capacity, do not assume it Capacity is decision-specific: he must be able to understand the information, retain it, weigh it and communicate a choice. He is disoriented to place and time, hallucinating and unable to explain the consequence of leaving, so his capacity to refuse treatment is currently impaired. That is a clinical judgement, recorded with the specific findings, not a label applied because he disagrees with staff.

Legal and ethical framework

• Under the Mental Healthcare Act, 2017, a person with impaired capacity may be admitted on an emergency basis by the medical officer in charge for up to 72 hours, after which the admission must be reviewed and regular admission procedures followed.
• Care must be in the least restrictive setting, with dignity, privacy and confidentiality, and no discrimination. Every restraint and seclusion must be recorded, reviewed and justified, and used only when less restrictive alternatives have failed.
• The nominated representative or family should be informed and involved, and his wishes and advance directive, if any, must be respected as far as capacity allows.

Practical steps

• Call the doctor now - this is a medical emergency, not a behavioural problem, and the benzodiazepine order should be given.
• Explain clearly and simply: you are not detaining him permanently, you are treating a condition that is dangerous for the next two days.
• Involve the wife, ask her not to agree to restraint herself, and document everything: time, findings, who was informed, what was said, and the response.
• If he does leave against advice and capacity is clearly impaired, escalate to the doctor and security, document, and arrange follow-up through the family; do not physically struggle with a potentially violent, delirious patient alone.