Substance withdrawal (suspected)

Any person, 16 years and over, presenting with actual or potential alcohol or drug withdrawal.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort Minimise stress by providing a quiet, calm, safe and private space Keep intoxicated patients under close observation until their intoxication diminishes and they are considered safe De-escalation techniques may be required for patients experiencing agitation or distress

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation, as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92% Monitor closely for aspiration pneumonia and/or respiratory depression

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern
IVC and/or pathology	Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Disability

Assessment	Intervention
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per specific treatment section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature – pyrexia is common in acute withdrawal	Measure temperature Maintain normothermia
Skin inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart, as required Encourage oral hydration
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment

Intervention

BGL

Measure BGL If patient is experiencing alcohol withdrawal or is at high risk of thiamine deficiency and is hypoglycaemic: give thiamine before glucose, or as soon as possible after. See thiamine section If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria): give quick-acting carbohydrate: sugary soft drink, fruit juice or 40% glucose gel, up to 15 g, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 4 mmol/L If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake: give 40% glucose gel, up to 15 g, buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose 200 mL by IV infusion over 15 minutes, once only if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes If the patient is unconscious or peri-arrest: give 50% glucose 50 mL by slow IV injection, once only. Use with caution as extravasation can cause necrosis if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Focused assessment

Complete substance withdrawal focused assessment.

Consider mental health focused assessment.

Clinical tips are provided in Management of Withdrawal from Alcohol and Other Drugs Clinical Guidance to support clinicians to provide care that meets the needs of patients from specific population groups undergoing substance withdrawal.

Precautions and notes

• Be familiar with any new or recent drug alerts available at Public drug warnings, NSW Health.
• Determine if the patient is currently a client of other service providers, and the need for their input while patient is in the emergency department.
• Delirium tremens (DTs) begins 48–72 hours after the last drink. DTs have serious medically associated risks, including changes to breathing, blood circulation, core body temperature and electrolytes.
• Thiamine is an essential vitamin in the body’s metabolic processes. Malnutrition is high in people with alcohol and drug dependence. Failure to restore thiamine can lead to Wernicke-Korsakoff syndrome or Wernicke encephalopathy.

Interventions and diagnostics

Specific treatment

• Continue to monitor and assess withdrawal symptoms, using appropriate opioid or alcohol withdrawal scale
• Refer to local drug and alcohol service promptly, if available

For patients less than 65 years and not pregnant:

• give diazepam 10 mg orally once only. Escalation is required for ongoing management
• continue hourly withdrawal scale and monitoring

• switch to acute behavioural disturbance protocol if required.

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Analgesia

If pain score 1–6 (mild–moderate): give paracetamol 1000 mg orally once only.

If severe pain present, give analgesia and escalate as per local CERS protocol.

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

• metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
• or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
• or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.

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Thiamine

If patient is experiencing alcohol withdrawal, or is at high risk of thiamine deficiency (e.g. those who drink large amounts of alcohol or who are severely malnourished), then:

• monitor using alcohol withdrawal scale
• give thiamine 300 mg IV/IM once only

If hypoglycaemic: thiamine should be given before glucose, or as soon as possible. Glucose can further deplete thiamine stores and precipitate Wernicke encephalopathy.

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Radiology

Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.

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Pathology

• FBC, UEC, LFT
• Alcohol withdrawal: coags

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au