Who needs it?   Not all alcoholics require inpatient detoxification.  Only those most at risk should be detoxified.  Err on the side of caution; once you get behind, it can be too late!

            Risk factors for withdrawal:
                - Age > 40        - Male gender       - > one fifth of alcohol consumed per day
                - abuse/dependence x more than 10 years
                - tremulousness or anxiety 6-8 hours after last drink
                - history of past withdrawal or seizures
                - acute medical problems, such as pneumonia
                - blood alcohol level > 250

            Add up all these risk factors:  0-2 = low risk; 3-6 = moderate; 7-9 = high risk.

            Also helpful: a serum magnesium level may help indicate seizure risk (supplement if low).

        What is the timecourse?    Autonomic hyperactivity can be seen within hours of stopping drinking.  Seizures tend to occur 1-3 days after the last drink.  Delirium tremens usually occurs 2-3 days after cessation of drinking, but can occur much later.  Visual hallucinations can occur anytime.

        What is the treatment?    Generally, a benzodiazepine such as chlordiazepoxide or lorazepam, is used to prophylax against alcohol withdrawal.  Longer-acting agents have the advantage of self-tapering so are generally preferred.  Shorter acting agents can produce micro-withdrawal between doses.    The benzodiazepine can be tapered over several days, allowing gradual detoxification and lowering the risk of seizures, DTs, and autonomic hyperactivity.
        Clonidine may also be helpful in controlling the autonomic hyperactivity of withdrawal, but will not prophylax against seizures.
        Nutritional supplementation is also important:  the typical alcoholic regimen includes thiamine 100 mg po qd, folate 1 mg po qd, and a multivitamin qd.  Thiamine should initially be given IV or IM to help avoid alcohol amnestic disorder.
        Vital signs should be checked regularly, at least every 4-6 hours for the first 24-48 hours of detoxification.  Generally speaking, a patient with normal blood pressure, pulse, and temperature is at low risk of withdrawal; conversely, elevation of any of these should alert you to escalating withdrawal, and stimulate you to increase the dosage of benzodiazepine.
        The orientation (to person, place, and time) of the patient, as well as the patient's overall mental status, should be closely monitored.