Delirium tremens (DT) represents the most severe form of alcohol withdrawal, characterized by delirium, autonomic instability, and a mortality rate approaching 15% without treatment. Although benzodiazepines and barbiturates remain the mainstay of therapy, a small subset of patients exhibit refractory withdrawal despite maximal dosing. Ethanol, historically used for alcohol withdrawal management, has largely fallen out of favor due to dosing challenges and safety concerns. However, recent reports suggest that carefully monitored enteral ethanol may offer therapeutic benefit in selected refractory cases.

We present a 49-year-old man with severe alcohol use disorder admitted after collapse and seizure following abrupt alcohol cessation. Despite escalating doses of benzodiazepines, phenobarbital (31 mg/kg), propofol, and dexmedetomidine, he remained severely agitated with life-threatening autonomic instability. After multidisciplinary discussion and informed consent, enteral ethanol was initiated via nasogastric tube, titrated to approximate his baseline daily intake (~34 mL of pure ethanol per dose).