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Rural Medicine – ETOH Withdrawal and Ice Fog

Mel Herbert, MD MBBS FAAEM, Vanessa Cardy, MD, FCFP, FRRMS, Sean Nordt, MD PharmD FAAEM, and Stuart Swadron, MD, FRCPC
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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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EMRAP 2018 08 August Vol.18 Written Summary 658 KB - PDF

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Birgitte M. -

In our institution, the pulmonologists have great success with Precedex.

Rick M. -

In the middle of listening to the Rural Medicine case of alcohol withdrawal. My very first thought was, knowing that they have limited medications and resources, why not have the patient start drinking vodka, whiskey or even beer, while he was still awake and coherent, before he got any worse. Prevention is better than playing catch up. Start weaning off alcohol when he was at a more appropriate facility. Best treatment to prevent alcohol withdrawal is alcohol. At the RAC Shock Trauma Center in Maryland, in the 90's, we used to Rx beer and whiskey to prevent withdrawal in patients who were not interested in stopping and would be going home in days or weeks. Titrated IV alcohol for those who could not drink. Benzo's less often or as back up.
Now, at a fully stocked hospital in a city, we use large doses of benzo's until requiring intubation, and then use propofol drip with Precedex as alternative if not responding adequately to propofol.

Vanessa C. -

Thanks for the comment and thoughts! And I love the suggestion but just one problem... this is ostensibly a dry community. No liquor stores. There are bootleggers for sure but ethics of community nurses asking bootleggers for illegal booze? Not so sure about that. Unlike the other Cree communities in our territory this particular village is only half dry, in that the Inuit side of the village does have a bar, but the Inuit and Cree are served by different health agencies and rules. So much more complicated than just giving them alcohol I fear. Would love to hear if anyone else working in a dry community has dealt with this by asking bootleggers for help

J. B. L., M.D. -

I find the Great White North fascinating. I remember as a teen ager writing the NWT for information on Frobisher Bay ( now Iqualit) and thnking about driving up to Maricourt quebec ( Quebec wasn't far from my home in the USA) and thinking about taking a ferry to Baffin island. Boy, was I dissappointed to find out that there are no roads that head that far north. I would be interested in knowing what comunity you serve, and what the coomunity that was involved was called ( so I can see them on a map) and how does the government provide medical care for these far flumng communities? Where do they get the doctors from? Do all communities get some kind of medical service? ( I would consider gogint to Grise Fjord~)

Vanessa C. -

Thanks for the reply. I work in Chisasibi, Quebec which is on the eastern edge of James Bay. The community where this particular story took place was Whapmagoostui or Great Whale or Kuujiuruapik which is on the lower eastern part of Hudson Bay. The "north" of Quebec is split into different health regions. My region is Region 18 and covers the 9 Cree communities. Region 17 is the region covering the Inuit villages in the province. There are nursing stations in each community and some have permanent doctor coverage but many have doctors coming in and out on a regular basis. The nurses in the communities are called "extended role" nurses. Not officially Nurse Practitioners but they receive additional training in how to manage many common chronic and urgent issues, and they are hard core as they manage so many things without the benefits of labs or X-rays or MD backup in many cases.

Thanks for the interest!

David W. -

As an aside, I know benzos are typically considered first line treatment for alcohol withdrawal, but I've started using phenobarbital as first line because it allows the patient to go home and not have to take any additional meds due to its long half life (~80 hours I believe)

Here is a good set of articles on the subject: https://emcrit.org/pulmcrit/phenobarbital-reloaded/

In addition, I know that the group who works @ Highland hospital in Oakland, CA uses phenobarbital for their alcohol withdrawal patients with good success. I believe their protocol is 130-260mg IV Q30 minutes to a max of 1040mg or so until the patient is lightly sedated (awakes to voice) and can still walk.

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EM:RAP 2018 August Full episode audio for MD edition 211:59 min - 295 MB - M4AEM:RAP 2018 August German Edition Deutsche 92:18 min - 127 MB - MP3EM:RAP 2018 August Aussie Edition Australian 2:27 min - 3 MB - MP3EM:RAP 2018 August Canadian Edition Canadian 14:57 min - 21 MB - MP3EM:RAP 2018 August French Edition Français 26:58 min - 37 MB - MP3EM:RAP 2018 August Spanish Edition Español 79:40 min - 109 MB - MP3EMRAP 2018 08 August Individual MP3 272 MB - ZIPEMRAP 2018 08 August Individual Summaries 935 KB - ZIPEMRAP 2018 08 August Vol.18 Written Summary 658 KB - PDFEM:RAP 2018 August Spanish Written 829 KB - PDFEMRAP Board Review Answers 2018 08 Aug Vol.18 08 284 KB - PDFEMRAP Board Review Questions 2018 08 Aug Vol.18 08 809 KB - PDF

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