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Alcohol Withdrawal

Rob Orman, MD and Bryan Hayes, PharmD, DABAT
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15:56
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Nurses Edition Commentary

Mel Herbert, MD MBBS FAAEM, Kathy Garvin, RN, and Lisa Chavez, RN
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03:34

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EM:RAP 2015 November Summary 665 KB - PDF

Alcohol withdrawal? Old school still works! Benzos baby!

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prestwig1 -

I feel that earlier use of Phenobarbital. in moderated to severe alcohol is very helpful. The Gaba receptor is pentameric in nature. Two Alpha subunits, Two beta subunits and a Gamma subunit. The binding of GABA is at one of two binding sites at the interface between the alpha and beta subunits (opens the receptor associated chloride channel) The Benzo binding site is at the interface between the alpha and gamma subunits. Barbiturates and alcohol bind to sites in the membrane-spanning transmembrane regions of the subunits.. So the Barbiturates act more like alcohol. Phenobarbital has a mean half life of 80 hours...What I often do is load with phenobarbital early (oral or iv) titrate with small doses of benzo's....Water, feed and discharge. So I benzo, benzo, benzo (still shaking) phenobarbital, "water, " feed," monitor discharge/admit. I think that the respiratory depressant fears of barbiturates in this population is unwarranted.

Sid Williamson -

I realize that ketamine was presented as a novel idea in this podcast but there is one aspect about this that I think would make this idea difficult in practice, and that is the reflex tachycardia and hypertension you get with sedation levels of ketamine. While vital signs are not the end all and be all of monitoring alcohol withdrawal, they are helpful in my experience. You might put someone down with ketamine but their vitals would mask real autonomic instability from withdrawal from the effects of ketamine itself. Maybe I'm missing something there, but it seems like ketamine might confuse the situation more than help it.

Jessie M. -

There was brief discussion of using gabapentin for discharge treatment of alcohol withdrawal...what would the dosing be for this? Our psych department asked us to use this if possible, and I have very little experience with it.

Michael A., MD -

In our ED we have a protocol, which has been in place for >10yrs. It is based on the CIWA score(Clinical Institute Withdrawal Assessment) and benzo's, Diazepam or Lorazepam,are administered based on the score. The scoring is done until 2 consecutive hours of a score less than 10. The patient gets either benzo, 20mg of Diazepam or 2mg of Lorazepam, hourly until the score is less than 10. Yes we can give big doses of either. My personal best with a patient is 140mg of Diazepam without respiratory depression. We also have protocol for treating seizures and hallucinosis in the same patient. If the patient has had known previous withdrawal seizures they get either of the BZ's for 3 doses regardless of the CIWA score. It is a nice protocol as patients are discharged without prescriptions and stabilized. It is also useful for patients being admitted for other med/surg problems and are know to be alcoholic, as they can be screened and recognized and treated sooner.

James C. -

I noted that there was no mention of antabuse in this discussion, and I've never used it myself. Has this drug fallen out of favor or is there still any role for it's use?

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Codes and Cath Labs Full episode audio for MD edition 231:38 min - 323 MB - M4AEM:RAP 2015 November Aussie Edition Australian 26:35 min - 36 MB - MP3EM:RAP 2015 November Canadian Edition Canadian 16:25 min - 23 MB - MP3EM:RAP 2015 Español Noviembre 2015 Español 72:56 min - 38 MB - MP3EM:RAP 2015 Novembre Résumé en Francais Français 53:50 min - 32 MB - MP3EM:RAP 2015 Español Noviembre 2015 1 MB - PDFEM:RAP 2015 November Board Review Answers 263 KB - PDFEM:RAP 2015 November Board Review Questions 232 KB - PDFEM:RAP 2015 November MP3 279 MB - ZIPEM:RAP 2015 November Summary 665 KB - PDF

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