EtOH withdraw, seizures, phenobarb and your comfort level

[Tipsy McStagger]

I've seen a lot of practice variation here, and a lot of varying comfort levels amongst providers. I'm interested in your approach.

Let's say you have a patient come in with suspected EtOH wthdraw seizure at home, no prior seizure or medical history, now clearly in withdraw.

1) What's your approach to these patients? Benzos? Phenobarbital?
2) Lets say you get their symptoms well under control with either of the above, have you ever sent them home? Do they 100% of the time need to come in to the hospital?

I ask because I've seen some providers who admit every EtOH withdraw seizure, and I've seen some who, if they control the symptoms, send them out. Where they train influences this decision significantly, but I'd like to hear your opinions.

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[BoardingDoc]

I've seen a lot of practice variation here, and a lot of varying comfort levels amongst providers. I'm interested in your approach.

Let's say you have a patient come in with suspected EtOH wthdraw seizure at home, no prior seizure or medical history, now clearly in withdraw.

1) What's your approach to these patients? Benzos? Phenobarbital?
2) Lets say you get their symptoms well under control with either of the above, have you ever sent them home? Do they 100% of the time need to come in to the hospital?

I ask because I've seen some providers who admit every EtOH withdraw seizure, and I've seen some who, if they control the symptoms, send them out. Where they train influences this decision significantly, but I'd like to hear your opinions.

If the pt has other issues such as significant electrolyte abnormalities, any trauma, has any lingering AMS: they get admitted. If they simply had a seizure and now have alcoholic tremulousness, benzos/barbs as needed.

I go between diazepam and chlordiazepoxide depending on where I'm working. Chlordiazepoxide is usually an easy winner. 50-100mg PO depending on how much of a drinker they are, then see how they settle out. Repeat if needed. If they're clinically sober and not shaky after that, they can leave. With diaz, I find I more often need to go to phenobarb afterwards (I don't have Librium at some places I work). 20mg up front, then double the dose everytime they're still scoring on a CIWA within an hour. E.g. if 20 does nothing after 15-30 min, they get 40. That doesn't work, 80. If 80 doesn't work, I just hit them with 10/kg of phenobarb. If that doesn't work, they get admitted. If it does work and they're clinically sober and independently ambulatory, they go home.

In the latter case, you need to be stone cold sober and stable as a rock, otherwise I'm liable to bring you in after that much medication. That said, it's the total quantity more than anything that I'm considering there. I've had people who drink several pints of vodka a day that I just start with 10/kg of phenobarb and if they're fine I am 100% comfortable sending them home.

 

[TheComebacKid]

I lean towards admitting them. About a third of patients with ETOH withdrawal seizures will progress to DTs. These patients often times look like crap, are extremely symptomatic, have high CIWA scores (I don't actually bother doing the score, but I can just tell by looking at them) and require repeat doses of benzos. I think it's worthwhile admitting them on a monitored bed, giving them fluids and observing them on an inpatient service.

If they just had a withdrawal seizure, you can achieve some sort of symptomatic control in the ED, are not tachycardic/diaphoretic etc, and you have a high suspicion that they will just go home and drink, perhaps they are safe to discharge.

 

[Tipsy McStagger]

20mg up front, then double the dose everytime they're still scoring on a CIWA within an hour. E.g. if 20 does nothing after 15-30 min, they get 40. That doesn't work, 80. If 80 doesn't work, I just hit them with 10/kg of phenobarb. If that doesn't work, they get admitted. If it does work and they're clinically sober and independently ambulatory, they go home.

Since you're giving them the phenobarb in this scenario, when they're going home are you giving anything else for at home use, or just the phenobarb since the half life is ~3 days?

 

[BoardingDoc]

Since you're giving them the phenobarb in this scenario, when they're going home are you giving anything else for at home use, or just the phenobarb since the half life is ~3 days?

In the phenobarb cases, I don't send them with anything, particularly since they're almost certainly going to drink again anyway. They all get detox resources and warned that stopping drinking is a great idea, but that they need to taper.

In select cases where I've given Librium I will send them home with a taper. This is generally only in my patients who I feel are more reliable and have a chance of actually wanting to get sober (and have said so).

 

[Rendar5]

Did they come I saying they had a seizure (usually lying if they look fine) or did they have a witnessed one. Usually the latter ends up getting admitted. I don’t treat those with seizures in withdrawals different than those without. The seizures are usually self-limited. If low CIWA score easily reached then dc and if high CIWA after initial tx usually warrants admission. If DT’s already present admit to ICU.

 

[Tipsy McStagger]

In the phenobarb cases, I don't send them with anything, particularly since they're almost certainly going to drink again anyway. They all get detox resources and warned that stopping drinking is a great idea, but that they need to taper.

In select cases where I've given Librium I will send them home with a taper. This is generally only in my patients who I feel are more reliable and have a chance of actually wanting to get sober (and have said so).

Sounds good, thanks for your insight!

 

[WilcoWorld]

Since you're giving them the phenobarb in this scenario, when they're going home are you giving anything else for at home use, or just the phenobarb since the half life is ~3 days?

This is an interesting (non-peer reviewed) bit of opinion on your question:

Alcohol Withdrawal, Meet Benzo Shortage - Emergency Physicians Monthly

 

[Tipsy McStagger]

This is an interesting (non-peer reviewed) bit of opinion on your question:

Alcohol Withdrawal, Meet Benzo Shortage - Emergency Physicians Monthly

Thanks for the read! EMcrit also has a good series on benzos vs barbs, here is the first of three articles

 

[RoyBasch]

I use valium for alcohol withdrawl. Have never used phenobarb for that indication. I almost always admit. In my view alcohol withdraw is a potentially fatal condition, sounds like a fairly solid admit to me. A lot of weaker **** gets admitted all the time.

The one exception would be mild cases well controlled with lose doses of benzos that are being transferred to some kind of detox center that has access to medication (I have learned over the years that a lot of places that advertise as detox centers actually have no medical personnel and no ability to administer medication of any kind. They are basically just places with no alcohol. Their staff seem shockingly unaware there is medical risk associated with cold turkey alcohol cessation).

Many of my partners will dc these patients with PO benzos, but this seems like a dubious strategy to me. For one, what if they need escalating doses? for two, I don't really like sending a person with known substance abuse home with controlled substances in possibly large doses.

Mind you my strategy is reserved for people who want to stop drinking. If someone simply had a withdrawl seizure because they were away from alcohol (typically jail) but are now free and able to keep drinking and that's what they want to do, then I have no problem discharging because these patients are very good at keeping their withdrawl at bay at home via staying drunk.

 

[WilcoWorld]

I think it's really important to recognize how context-dependent the appropriate treatment for withdrawal is.

Take three patients who had a seizure, have no significant head injury/electrolyte abnormalities, and now have mild tremors with borderline HTN & a heart rate of 90.

The homeless person who presents during coldpocalypse, has no money for librium, and your hospital has plenty of monitored beds available with nurses comfortable doing a CIWA scale-based treatment on the floor: admit on push dose midazolam.

The 40 yo cop who decided to quit cold turkey on Wednesday, but presented after a seizure on Friday. Your town has a detox center that will administer PO meds and the patient can follow up to sart an outpatient treatment program on Monday. DC to detox with a Librium taper.

The chronic alcoholic who only quits drinking when he can't get the $$$ to buy booze. He presents to your ED while all the ICU beds are full, it's Monday so the waiting room is filling up, and hospital policy requires anyone who needs IV benzos more often than Q4 has to go to an ICU (no wonder their beds are full!). Load with phenobarbital, reassess in 30 minutes, redose if needed, and admit to the floor once stabilized.

There is no single right way to manage withdrawal. Same patient (based on vitals/labs/imaging/chief complaint) + different contexts = different management.

 

[Groove]

I don't use phenobarb at all due to the half life. A lot of these alcoholics abuse narcotics and other drugs and even if you let them go, most likely are going to abuse alcohol again and with phenobarb on board they are at much higher risk for overdose and respiratory failure. The only times I give phenobarb are with the status patients and to be honest, it's been years since I couldn't get a seizure stopped with anything else and was forced to put them into a phenobarb coma.

If they had a seizure and I think it was alcohol induced, I admit 100% of these guys. Most are going to at the very least have a CIWA > 10 and it's an easy admission. Let medicine get them chilled out and initiate the librium tapers. If you are routinely getting pushback for these guys (especially with seizures) then consult neuro and obtain buy in to buff the admission. Done.

For the CIWA < 10, trustworthy pt, and no seizures or other high risk features, I'll initiate a librium or valium taper with close f/u with outpt resources.

 

[Birdstrike]

I've seen a lot of practice variation here, and a lot of varying comfort levels amongst providers. I'm interested in your approach.

Let's say you have a patient come in with suspected EtOH wthdraw seizure at home, no prior seizure or medical history, now clearly in withdraw.

1) What's your approach to these patients? Benzos? Phenobarbital?
2) Lets say you get their symptoms well under control with either of the above, have you ever sent them home? Do they 100% of the time need to come in to the hospital?

I ask because I've seen some providers who admit every EtOH withdraw seizure, and I've seen some who, if they control the symptoms, send them out. Where they train influences this decision significantly, but I'd like to hear your opinions.

Give cheap, generic benzos all day long. There's no need to get fancy with this or make it more complicated than it needs to be. Benzos will stop alcohol withdrawal seizures near 100% of the time, if you give enough.

In an ideal world, with unlimited resources and plentiful patient desire for help, you'd admit all of these. But think logically about this, not like you're trying to remember ingredient #10 in a cookbook. In reality, hardcore alcoholics run dry and shake & seize like a jack hammers as often as the wind blows. And they know how to stop their seizures quicker and more reliably than you do: With alcohol. And it works every time. Every alcoholic knows that if you don't drink, you'll shake and if you drink, you won't. And they'll spend more effort and waking energy trying to keep it from happening, than you ever could.

So you have to ask yourself what's the purpose, the end goal, of the admission?

If there's a good reason for admission, with an achievable goal in sight, then yes, admit them. It could be a medical reason, a social reason, or other. But there needs to be a reason other than putting Johnny on a CNS depressant drip forever, if he's just going to do home and do the same exact thing, from 5 seconds after discharge to eternity.

 

[d2305]

Antabuse is useful for the Pts who want to stop. I was the top antabuse prescriber in Fl in the early 2000. It was still brand name, and the drug rep came around.

 

[Epinephreus]

I don't use phenobarb at all due to the half life. A lot of these alcoholics abuse narcotics and other drugs and even if you let them go, most likely are going to abuse alcohol again and with phenobarb on board they are at much higher risk for overdose and respiratory failure. The only times I give phenobarb are with the status patients and to be honest, it's been years since I couldn't get a seizure stopped with anything else and was forced to put them into a phenobarb coma.

If they had a seizure and I think it was alcohol induced, I admit 100% of these guys. Most are going to at the very least have a CIWA > 10 and it's an easy admission. Let medicine get them chilled out and initiate the librium tapers. If you are routinely getting pushback for these guys (especially with seizures) then consult neuro and obtain buy in to buff the admission. Done.

For the CIWA < 10, trustworthy pt, and no seizures or other high risk features, I'll initiate a librium or valium taper with close f/u with outpt resources.

I may be biased since I am currently a resident in the Bay area which tends to be a very phenobarbital heavy region thanks to all the research that came from Highland, however, I have a very different view of Phenobarb.

In my experience, phenobarb is SAFER than benzos if you are going to discharge a patient to the street, and there are many other advantages as well. It takes a 20 mg/kg (we're talking 1400-2000 mg) dose in a non-withdrawing patient to cause respiratory depression.

• mild WD symptoms in the ED but are being discharged (typically wd because in ED for long enough time without a drink) - give 130 phenobarb watch 20 mins, discharge.
• more moderate withdrawal without complications -> 260 + 130 mg q 30 mins - typically don't need more than 520 mg, admit if they want help - discharge if they dont
• severe symptoms of alcohol withdrawal +/- complications (ie sz) -> 10 mg/kg load -> typically coming in, tends to curb need for ICU often
• Status/DTs - Intubate and phenobarb vs propofol gtt.

Benefits:
- Phenobarb appears to work better for alcohol withdrawal than benzos: PulmCrit- Phenobarbital monotherapy for alcohol withdrawal: Reloaded
- Patient's don't frequent the ED for minor WD symptoms so they can simply get benzos.
- Giving a dose of phenobarb, observing for 30 mins and discharging is safer than sending someone who is going to go drink out with a librium taper (our tox fellows harp us on all our bad outcomes over the last years from dcing patient's with librium tapers.

Disadvantages:
- Medicine not as familiar with phenobarb, so if being admitted to the floor - receiving team may be less familiar. Not as much an issue if patient going to ICU.

My 2 cents! Like all things in medicine, there are 5 ways to skin the cat. Just don't discount Phenobarb as it may really surprise you at how much you enjoy using it.

 

[Renaissance Man]

Antabuse is useful for the Pts who want to stop. I was the top antabuse prescriber in Fl in the early 2000. It was still brand name, and the drug rep came around.

Do you still prescribe it? I have never seen Antaabuse written for, and am genuinely curious. How long of a course do you give out? I would be concerned the patient population never receiving follow-up or drinking with it anyways and having severe complications (obviously minor side effects are the intended).

 

[Zebra Hunter]

Agree that phenobarbital is much than benzos for withdrawals. I made the switch to phenobarbital since leaving residency (attendings never let me give it due to comfort level) and I will likely never go back. I have never had to re-dose phenobarbital the way we are frequently re-dosing with benzos. Also, frequently I’ve been able to avoid ICU admission in severe cases.

 

[d2305]

I have not seen a practiced in a couple of years. I became familiar with antabuse in Navy as I used to have a line form up at my sick bay door for their daily 250mg antabuse tablet. I never saw any untoward effects from it unless they drank etoh. Surprisingly, it doesn't work on everyone, but it usually does work well.

When I retired from the Navy, I worked in FP and somehow a local judge sent me all his dui repeaters for antabuse. He gave them a choice of jail or antabuse. I would give them a 30 day supply with 11 refills. I think a probation officer kept up with them.

In urgent care, I would have alcoholics wander in that wanted to stop drinking. Antabuse is a useful crutch that prevents them from picking up the first drink. I did get a CMP on unhealthy looking patients, but antabuse isn't as hepatotoxic as etoh or INH.

 

[Groove]

I may be biased since I am currently a resident in the Bay area which tends to be a very phenobarbital heavy region thanks to all the research that came from Highland, however, I have a very different view of Phenobarb.

In my experience, phenobarb is SAFER than benzos if you are going to discharge a patient to the street, and there are many other advantages as well. It takes a 20 mg/kg (we're talking 1400-2000 mg) dose in a non-withdrawing patient to cause respiratory depression.

If I have a patient who has mild WD symptoms in the ED but are being discharged (typically wd because in ED for long enough time without a drink) - give 130 phenobarb watch 20 mins, discharge.
If I have a patient who appears to have more moderate withdrawal without complications -> 260 + 130 mg q 30 mins - typically don't need more than 520 mg.
If a patient has severe symptoms of alcohol withdrawal +/- complications (ie sz) -> 10 mg/kg load -> typically coming in, not always.
Status/DTs - Intubate and phenobarb vs propofol gtt.

Benefits:
- Phenobarb appears to work better for alcohol withdrawal than benzos: PulmCrit- Phenobarbital monotherapy for alcohol withdrawal: Reloaded
- Patient's don't frequent the ED for minor WD symptoms so they can simply get benzos.
- Giving a dose of phenobarb, observing for 30 mins and discharging is safer than sending someone who is going to go drink out with a librium taper (our tox fellows harp us on all our bad outcomes over the last years from dcing patient's with librium tapers.

Disadvantages:
- Medicine not as familiar with phenobarb, so if being admitted to the floor - receiving team may be less familiar. Not as much an issue if patient going to ICU.

My 2 cents! Like all things in medicine, there are 5 ways to skin the cat. Just don't discount Phenobarb as it may really surprise you at how much you enjoy using it.

There just aren't any well powered RCTs showing convincing superiority of barbiturates vis-a-vis benzos. The new EBM regarding their use is cool, but let's face it...scant in the grand scheme of things. Benzo's have the largest and best evidence base for the treatment of alcohol withdrawal. It's also currently standard of care in our specialty. Now, that may change in the future, but for the moment, anywhere you go (most places at least)... it's benzo's. Why? Because they work so damn well. I've been doing this for 10 years and benzos work great. Why are we even trying to re-invent the wheel? It is the extreme rare incidence where I've had any complications with their use in the context of AW. It seems to be only the past few years that I see sporadic research interested in a push for phenobarb.

All of the phenobarb monotherapy is something that seems like it would be very cool to do in an academic center where everyone is trying to do something new and different and attendings are struggling to create unique and original teaching points and obsessed with being on the front lines of FOAMed therapy. That's great, but please get familiar with using benzos. When you get out in the real world, most medicine docs are going to be utterly unfamiliar with barbiturate mono therapy for alcohol withdrawal and are going to flip out when you try to admit a pt to them after pushing phenobarb. Also, again... take your pt population into consideration. Most of my alcoholics are all addicts and very prone to relapse on booze and pills once I send them out the door. The medicine you're giving them has a half-life of 80 hours. If you have a bad outcome, your local friendly litigation lawyers are going to introduce you to a term called "regional standard of care". They will hold you to whatever standard of care is most commonly practiced among other EPs in your area. Not only is phenobarb likely not the regional standard of care, but it's not even the national standard of care. That may seem overly cautious but may make more sense after you've gotten out on your own, been involved in some expert witnessing or been involved in your first suit.

All that being said, I will freely admit that there is some evidence to support phenobarb. I just don't consider it enough evidence to change my practice.

 

[Apollyon]

Although possible, it's just really, really a lot harder to kill yourself with benzos than it is with barbiturates. Or, alternately, a lot easier to kill ones self with barbiturates than benzos.

 

[Epinephreus]

Although possible, it's just really, really a lot harder to kill yourself with benzos than it is with barbiturates. Or, alternately, a lot easier to kill ones self with barbiturates than benzos.

Just want to iterate that patients are not being discharged with prescriptions for Phenobarb. They are receiving it in the ED and being discharged once they are appropriate from a withdrawal standpoint!

 

[gutonc]

Just want to iterate that patients are not being discharged with prescriptions for Phenobarb. They are receiving it in the ED and being discharged once they are appropriate from a withdrawal standpoint!

Was that not clear to somebody?

 

[Apollyon]

Was that not clear to somebody?

Did you need to post that? It sounds sarcastic.

For me, at least, it clears it a bit.

 

[WilcoWorld]

Just want to iterate that patients are not being discharged with prescriptions for Phenobarb. They are receiving it in the ED and being discharged once they are appropriate from a withdrawal standpoint!

And I'll add that at this point the phenobarbital has reached its peak effect.

 

[thegenius]

I don't use phenobarb at all due to the half life. A lot of these alcoholics abuse narcotics and other drugs and even if you let them go, most likely are going to abuse alcohol again and with phenobarb on board they are at much higher risk for overdose and respiratory failure. The only times I give phenobarb are with the status patients and to be honest, it's been years since I couldn't get a seizure stopped with anything else and was forced to put them into a phenobarb coma.

Very interesting...i hear ya on that. hmm...

I used to use valium exclusively: 10 mg, 20 mg, 20 mg, (I rarely need more after this), 40 mg, (at this point I will admit), .....

Valium IV is on national shortage and we haven't had it in some time. For whatever reason I don't use ativan, many of my partners do.

Now for the last year I've been using phenobarbital. I know loading dose is 10/kg, but for whatever reason, probably the way I've been taught, I start with 260, then give 130 q15-30 minutes until I achieve normalcy.

I've never considered the potential problem with phenobarb coma, interesting.


I think the hardest problem with these people is deciding on what to discharge them on if they want a taper or want to quit. I hate sending people out on librium. Recently I've been using carbamazepine or gabapentin.

 

[alpinism]

Had one today:

Alcoholic with severe frostbite of both hands admitted to surgery boarding in the ER due to lack of beds.

Got phenobarbital 260mg x 10 doses still tachy in the 150s and wide awake.

Ended up tubing him with 500mg propofol.

 

[thegenius]

You work in Haiti? Frostbite in Haiti?

 

[Epinephreus]

Was that not clear to somebody?

Thanks for this "helpful" response.

My interpretation of the conversation was that there were some concerns about discharging people with rx for phenobarb similar to how you would a Librium taper. Wanted to clarify since the overwhelming majority of readers are learners.

 

[Psai]

You work in Haiti? Frostbite in Haiti?

Global warming man

 

[Zebra Hunter]

There just aren't any well powered RCTs showing convincing superiority of barbiturates vis-a-vis benzos. The new EBM regarding their use is cool, but let's face it...scant in the grand scheme of things. Benzo's have the largest and best evidence base for the treatment of alcohol withdrawal. It's also currently standard of care in our specialty. Now, that may change in the future, but for the moment, anywhere you go (most places at least)... it's benzo's. Why? Because they work so damn well. I've been doing this for 10 years and benzos work great. Why are we even trying to re-invent the wheel? It is the extreme rare incidence where I've had any complications with their use in the context of AW. It seems to be only the past few years that I see sporadic research interested in a push for phenobarb.

All of the phenobarb monotherapy is something that seems like it would be very cool to do in an academic center where everyone is trying to do something new and different and attendings are struggling to create unique and original teaching points and obsessed with being on the front lines of FOAMed therapy. That's great, but please get familiar with using benzos. When you get out in the real world, most medicine docs are going to be utterly unfamiliar with barbiturate mono therapy for alcohol withdrawal and are going to flip out when you try to admit a pt to them after pushing phenobarb. Also, again... take your pt population into consideration. Most of my alcoholics are all addicts and very prone to relapse on booze and pills once I send them out the door. The medicine you're giving them has a half-life of 80 hours. If you have a bad outcome, your local friendly litigation lawyers are going to introduce you to a term called "regional standard of care". They will hold you to whatever standard of care is most commonly practiced among other EPs in your area. Not only is phenobarb likely not the regional standard of care, but it's not even the national standard of care. That may seem overly cautious but may make more sense after you've gotten out on your own, been involved in some expert witnessing or been involved in your first suit.

All that being said, I will freely admit that there is some evidence to support phenobarb. I just don't consider it enough evidence to change my practice.

Regarding your litigation fears, the same risk is present with handing out Librium tapers. Or discharging after giving a dose of Valium. Also, 130mg of phenobarbital ain’t gonna cause severe respiratory depression when that patient decides to drink three hours after being discharged.

As for benzos, I find them to be less effective and more frequently requiring redosing, where most of the time I’m giving just a single dose of phenobarbital. And with the shortage of IV Valium, there is no way I’m using Ativan due to it being a terrible choice for withdrawals given the relatively short half-life.

 

[Epinephreus]

Regarding your litigation fears, the same risk is present with handing out Librium tapers. Or discharging after giving a dose of Valium. Also, 130mg of phenobarbital ain’t gonna cause severe respiratory depression when that patient decides to drink three hours after being discharged.

As for benzos, I find them to be less effective and more frequently requiring redosing, where most of the time I’m giving just a single dose of phenobarbital. And with the shortage of IV Valium, there is no way I’m using Ativan due to it being a terrible choice for withdrawals given the relatively short half-life.

Also a good point. On my ICU rotations, it sucks receiving patients initially treated with Ativan (our hospital basically has stopped using valium for WD all together due to the shortage) because they typically can't really be switched to another agent if failing Ativan (benzos and barbs mixed become less predictable) unless considering intubation and if the patient needs to be put on an Ativan gtt, they get weird acidoses and other metabolic abnormalities - thanks propylene glycol.

 

[WilcoWorld]

I know loading dose is 10/kg, but for whatever reason, probably the way I've been taught, I start with 260, then give 130 q15-30 minutes until I achieve normalcy.

Ha, I do that too. It comes in 130mg vials, so it's usually dosed in multiples of that.

 

[alpinism]

You work in Haiti? Frostbite in Haiti?

I'm back in Detroit at the moment.

 

[Atlas Shrugged]

In military hospitals most are admitted and put on CIWA with diazepam or chlordiazepoxide. It seems crazy to me that someone with alcohol withdrawal would be discharged from the ED when it can be fatal so often. We have the benefit of active duty not being able to leave AMA.

 

[gro2001]

I am just going to throw some shade and say that it seems insanely irresponsible to discharge someone who had a seizure in the setting of alcohol withdrawal and continues to show signs of alcohol withdrawal at the time of evaluation. I wonder if people who do that have just not seen enough severe alcohol withdrawal. Because if you have, the decision to admit is unambiguous.

 

[Groove]

I am just going to throw some shade and say that it seems insanely irresponsible to discharge someone who had a seizure in the setting of alcohol withdrawal and continues to show signs of alcohol withdrawal at the time of evaluation. I wonder if people who do that have just not seen enough severe alcohol withdrawal. Because if you have, the decision to admit is unambiguous.

Totally agree. If I had to choose some of the most potentially complicated patients from a medical standpoint, it would be ESRD, chronic alcoholics closely followed by SLE patients.

 

[Groove]

Regarding your litigation fears, the same risk is present with handing out Librium tapers. Or discharging after giving a dose of Valium. Also, 130mg of phenobarbital ain’t gonna cause severe respiratory depression when that patient decides to drink three hours after being discharged.

As for benzos, I find them to be less effective and more frequently requiring redosing, where most of the time I’m giving just a single dose of phenobarbital. And with the shortage of IV Valium, there is no way I’m using Ativan due to it being a terrible choice for withdrawals given the relatively short half-life.

In regards to the litigation standard, again... benzo's are standard of care, regional and national. Librium, valium, ativan being the most commonly used. Hell, they are the first recommended drugs on uptodate and benzo's are the only drugs recommended in virtually any EM text (I checked with the latest Rosens). That may not be reflective of some new literature supporting phenobarb (which I never saw until we had a shortage). However, from a legal standpoint, you have much more of a leg to stand on. I'm certainly not saying you couldn't win a case involving phenobarb but I'm just making a point... It wouldn't be unheard of for them to find an "expert witness" willing to say that you're therapy was well outside the norm and "experimental" or "unproven".

Anecdotally, I'm not saying your personal experience is faulty, but what I'm saying is there are virtually no studies showing superiority of phenobarb vs benzos for alcohol withdrawal. Even the three recently mentioned in Annals admitted there was no improved benefit, no decreased ICU admission, no decreased adverse effects, nothing... They only admitted that phenobarb should be considered...when you are out of benzos.

Comparison of phenobarbital-adjunct versus benzodiazepine-only approach for alcoholwithdrawal syndrome in the emergency department.

CONCLUSION:
Adjunctive phenobarbital use in the ED for alcohol withdrawal syndrome did not result in decreased ICU admission, severity of symptoms, or complication

Benzodiazepines vs barbiturates for alcohol withdrawal: Analysis of 3 different treatment protocols.

Of note, the impetus for all of these research studies stemmed from the shortage of benzodiazepine.

"Benzodiazepines are the standard of care, with rapid onset and long durations of action. Recent drug shortages involving IV benzodiazepines have required incorporation of alternative agents into treatment protocols"

I get the newfound fascination among some with using something new, especially when faced with a benzo shortage but if you don't have a shortage of benzo's...I can't help but wonder why would I use something with a much lower therapeutic index, and a much longer half life when I can't get superior results?

 

[thegenius]

I get the newfound fascination among some with using something new, especially when faced with a benzo shortage but if you don't have a shortage of benzo's...I can't help but wonder why would I use something with a much lower therapeutic index, and a much longer half life when I can't get superior results?

I think that is the point with much longer half-life...it’s really long and provides relief and gives one confidence they will have enough time to find their next drink.

I used phenobarb regularly (but not always) and haven’t had a problem with it, but I don’t know what I would do with a real bad withdraw with HR 150, sweating and BP 160-115. There is a national shortage of valium IV

 

[Old_Mil]

I've seen a lot of practice variation here, and a lot of varying comfort levels amongst providers. I'm interested in your approach.

Let's say you have a patient come in with suspected EtOH wthdraw seizure at home, no prior seizure or medical history, now clearly in withdraw.

1) What's your approach to these patients? Benzos? Phenobarbital?
2) Lets say you get their symptoms well under control with either of the above, have you ever sent them home? Do they 100% of the time need to come in to the hospital?

I ask because I've seen some providers who admit every EtOH withdraw seizure, and I've seen some who, if they control the symptoms, send them out. Where they train influences this decision significantly, but I'd like to hear your opinions.

I admit them all. If for no other reason than they've demonstrated an unwillingness not to drink heavily, that I've given them and may have to give them more Benzos, and I don't really want to have a discussion with a malpractice lawyer about why I sent home an alcoholic with Benzos on board who then proceeded to drink himself to death upon discharge with the benefit of medications I ordered or prescribed. But a great deal of what I do and chart is aimed at avoiding discussions with malpractice lawyers.

 

[TooMuchResearch]

I am just going to throw some shade and say that it seems insanely irresponsible to discharge someone who had a seizure in the setting of alcohol withdrawal and continues to show signs of alcohol withdrawal at the time of evaluation. I wonder if people who do that have just not seen enough severe alcohol withdrawal. Because if you have, the decision to admit is unambiguous.

Nah, I just have some patients that once I get their withdrawal under control are able to vocalize and hold a full conversation on how they're not staying in the hospital and already called a taxi or friend to pick them up. It happens that one of these guys that comes to mind has also been intubated by my colleagues multiple times in the past couple years, so it really just depends on the stars or orientation of the planets or whatever on the days I happen to see him.

 

[thegenius]

I go by vital signs and the amount of benzodiazepines / phenobarb I've given them. I don't care too much about whether they had a seizure. Especially since most who had one, or claim they had one, end up having mild vital sign abnormalities when I see them in the ED and it's hard to actually verify they had a seizure. Just my cohort here in California.

If you had a seizure, bit your tongue, and are sweaty with a HR 150 and BP 160/110, then I will admit you regardless of how much medicine I give you.

For me it's situational. It was said above
"I wonder if people who do that have just not seen enough severe alcohol withdrawal."

I doubt most, if not all ER docs would ever discharge severe alcohol withdraw with (or even without) a seizure.

 

[The Knife & Gun Club]

I admit them all. If for no other reason than they've demonstrated an unwillingness not to drink heavily, that I've given them and may have to give them more Benzos, and I don't really want to have a discussion with a malpractice lawyer about why I sent home an alcoholic with Benzos on board who then proceeded to drink himself to death upon discharge with the benefit of medications I ordered or prescribed. But a great deal of what I do and chart is aimed at avoiding discussions with malpractice lawyers.

Does this include holding them against their will? Or will you let them leave AMA if they are physically walking out the door?

 

[deleted859535]

Does this include holding them against their will? Or will you let them leave AMA if they are physically walking out the door?

A good question. The second they prove they do not have the capacity to decide AMA in the eyes of a reasonable boarded emergency physician, they get "involuntary care."

Just from a medicolegal perspective and to say nothing of how it's also medically a sound decision, far better to defend having done so than to defend having not done so.

 

[emergentmd]

This all depends on their social situation and risk factors.

Well appearing asymptomatic person on exam with a witnessed W/D seizure.

Homeless - admit very day

Normal guy with family watching him, home with benzo and close PCP follow up.

 

[Candidate2017]

Does this include holding them against their will? Or will you let them leave AMA if they are physically walking out the door?

You call security. They do not have decision making capacity if they have alcohol withdrawal.

 

[Candidate2017]

Also a good point. On my ICU rotations, it sucks receiving patients initially treated with Ativan (our hospital basically has stopped using valium for WD all together due to the shortage) because they typically can't really be switched to another agent if failing Ativan (benzos and barbs mixed become less predictable) unless considering intubation and if the patient needs to be put on an Ativan gtt, they get weird acidoses and other metabolic abnormalities - thanks propylene glycol.

This happens often when a patient is admitted for non-alcohol reasons without anyone taking an accurate alcohol history. By the time the floor team notices and puts them on CIWA, it's too late and they get sent to the ICU and get Precedex'ed. A 3 day stay turns into 2 weeks.

 

[Candidate2017]

I've seen a lot of practice variation here, and a lot of varying comfort levels amongst providers. I'm interested in your approach.

Let's say you have a patient come in with suspected EtOH wthdraw seizure at home, no prior seizure or medical history, now clearly in withdraw.

1) What's your approach to these patients? Benzos? Phenobarbital?
2) Lets say you get their symptoms well under control with either of the above, have you ever sent them home? Do they 100% of the time need to come in to the hospital?

I ask because I've seen some providers who admit every EtOH withdraw seizure, and I've seen some who, if they control the symptoms, send them out. Where they train influences this decision significantly, but I'd like to hear your opinions.

I'd rather the ED ask to admit these patients. The IM team will usually consult psych, and I'll see them in the AM and put them to sleep for 2-3 days with around the clock BZDs. No BZDs on DC, ever.

 

[Dr Mantis Toboggan]

Florid DTs clearly not, but a mildly tremulous patient with clear sensorium and without SI/HI who says look, I’m not staying I just want to go out and drink. We strap that guy down against his will?

You call security. They do not have decision making capacity if they have alcohol withdrawal.

 

[TooMuchResearch]

You call security. They do not have decision making capacity if they have alcohol withdrawal.

They might have decision making capacity.

 

[Zebra Hunter]

This happens often when a patient is admitted for non-alcohol reasons without anyone taking an accurate alcohol history. By the time the floor team notices and puts them on CIWA, it's too late and they get sent to the ICU and get Precedex'ed. A 3 day stay turns into 2 weeks.

It turned into 2 weeks because you're using Precedex for alcohol withdrawal. Don't do that, it is one of the worst possible medications you can give to an individual in acute withdrawals.

It is the equivalent of only giving a septic patient a dose of tylenol and a beta blocker rather than abx and fluids and claiming you're treating them because their HR and temp have improved.