A 40-year-old chronic alcoholic presents at 48 hours of abstinence with tremors, sweating, hypertension, tachycardia, and visual hallucinations. He is oriented to time and place. CIWA-Ar score is 22. Which is the MOST appropriate treatment?
- A IV haloperidol for hallucinations
- B Oral diazepam symptom-triggered protocol ✓
- C Naltrexone 50 mg daily
- D Disulfiram 250 mg immediately
Correct answer: B. Oral diazepam symptom-triggered protocol
Explanation
A CIWA-Ar score of 22 indicates moderate-severe alcohol withdrawal requiring treatment. Benzodiazepines (diazepam or lorazepam) are the gold standard for alcohol withdrawal, preventing progression to delirium tremens and seizures. Symptom-triggered dosing (benzodiazepines given when CIWA-Ar >8-10) uses less medication than fixed-dose schedules. Antipsychotics do not prevent seizures. Naltrexone and disulfiram are used for relapse prevention AFTER detoxification, not during acute withdrawal.
Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.
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