T.R. Eckler (2): it was one of those rare moments where the family, looks
at you and goes, what did you do?
And you say, ah, you know, had a thought, had a hunch.
Sam (2): Hi everyone, and welcome to another episode of EMplify.
I'm your host, Sam Ashoo.
Before we dive into this month's episode, I want to say happy Thanksgiving.
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have a wonderful Thanksgiving.
And now let's jump into this month's episode.
Sam: All ladies and gentlemen, welcome back to another episode of Emplify.
I am one of your hosts, Sam Ashoo, and on the other end of the microphone
T.R. Eckler: Dr. TR Eckler, just like barbiturates.
I am back baby.
Sam: here to talk about barbiturates only and why you should be using them,
T.R. Eckler: Also gabapentin, that's really gonna be a theme for me today.
Sam: Okay.
All right.
There you have it.
There's the summary.
Thanks for joining us everybody, and until next.
Oh wait, we're not done yet.
T.R. Eckler: High yield quick hits.
Sam: That's right.
That's super quick.
What are we talking about today?
We're talking about the emergency medicine practice article from November,
2025, authored by Dr. Koo on the diagnosis and management of ED patients
with alcohol withdrawal syndrome.
A very timely article given the holidays coming up.
Many people seem to seek solace in alcohol inappropriately or maybe appropriately.
I don't know.
I don't know your families, but it's definitely something we're going to see.
We see it here frequently in Tallahassee, around weekends, Friday
nights, Saturday nights, football weekends, homecoming college students.
And so this is a, a very timely topic and quite relevant to the emergency department
and once again, an outstanding article.
Some interesting introductory statistics.
I thought it was interesting to see that the data on alcohol intoxication and ED
visits shows that there's actually been an increase steadily over the last decade
for ED visits related to alcohol use.
And mortality from alcohol withdrawal ranges anywhere from one to 5%.
That's mortality.
So that's death we're talking about there.
And among heavy alcohol users admitted to the hospital, that climbs a little higher,
just a kind of peeking around 7% or so.
So it's not a simple problem to fix.
And the spectrum of patients here runs the gamut.
You got the people who are gonna go home and you got the people
who are gonna go to observation.
You got the people who have to be admitted to inpatient, and then
you got the critically sick who are going to the ICU and we're
gonna talk about all of them today.
T.R. Eckler: this is not just kind of your alcoholic that shows up
disheveled on the EMS stretcher.
Like, you know, I've seen so many different iterations of alcoholic
patients come in that I've just learned to develop a really high
suspicion for this kind of thing.
I knew someone in medical school whose father went in for like a normal surgery
and went into alcohol withdrawal and died 'cause nobody really kind of
knew that he was drinking that much.
I've seen so many complications from the patient that seemed intoxicated
or delirious that actually also had a head bleed or also had, co ingestion
or they had also overdosed on Tylenol.
And there's just so much complexity in pathology and this is just such
bread and butter, you know, really challenging emergency medicine, that
it's a great thing to really think hard about every time you have one of these
patients as to how much you wanna work 'em up and whether they're getting
better, whether you need to do more.
Sam: Yeah.
Yeah, that's well said.
And even, you know, these patients, much like the patients we talked about
previously with adrenal insufficiency, these patients can present with alcohol
withdrawal as their primary diagnosis.
It can be a secondary diagnosis, it can be because of some other thing going
on, and they can't drink alcohol, which is what's thrown them into withdrawal.
And it can mimic sepsis and drug intoxication.
So this becomes a very pertinent diagnosis and one that you have to
have a high suspicion for, for sure.
And I thought the author did a great job of of course finding an evidence
base for all the recommendations, but also saying, Hey, you know, there is
kind of a, a paucity of good evidence because it's hard to get informed
consent for this population in general.
And there's a lack of a homogenous population, meaning that there's
such a variety, like I mentioned before, from the people going home
to the people going to the ICU.
It's difficult to find something that works in general for that
entire spectrum, and we end up talking about things that work for
specific segments of this population.
If you're not aware, under typical conditions, about 90% of your ingested
alcohol is absorbed within an hour.
It's a nice little tidbit there.
And another one is that absorption occurs starting in the gastrum or in the
stomach, and your gastric mucosa have alcohol dehydrogenase in them, which is
actually higher in males than in females.
Which therefore leads to a higher bioavailability of
alcohol in females and males.
That's one of the reasons.
But also in your patients who've had gastric bypass surgery will have less
alcohol dehydrogenase secretion in the stomach to metabolize alcohol.
So there are small amounts of alcohol that are excreted in the kidneys
and in the lungs and in the sweat.
But most of it is going to be metabolized by the liver and eventually turned
into acetaldehyde and hopefully then goes through that wonderful
kreb cycle that we all remember.
But the acetaldehyde, if it builds up enough, is what gives you that kind of
the hangover cluster of symptoms and the severity of that is directly dependent to
the amount of alcohol that you consumed, because you can overwhelm that enzyme that
breaks down the alcohol and lead to a lot of this stuff building up in your system.
And so if you have someone who is alcohol intoxicated, your typical
metabolism is going to be about 20 milligrams per deciliter per hour.
And if they're an experienced alcoholic, they can upregulate those enzymes and
metabolize, you know, anywhere from 25 to 35 milligrams per deciliter per hour.
But it isn't gonna go any much faster than that.
So even in your chronic alcoholic who's got a sky high alcoholic level, you're
gonna be watching those people if they're heavily intoxicated for a long, long time.
Which brings me to my first question in trivia with TR.
Oh yeah, you forgot we do that now, don't we?
Here we go.
This is uh, easy, easy, multiple choice.
Which of the following is a primary mechanism by which chronic alcohol use
alters neuro transmission in the brain?
All right, here we go.
Activation of the NMDA receptor by alcohol.
Decreased GABAergic activity during alcohol consumption, downregulation
of GABA receptors and upregulation of the NMDA receptors, inhibition
of the CYP two E one enzyme or stimulation of serotonin release.
So which of these is the primary mechanism by which chronic alcohol use
alters neuro transmission in the brain?
T.R. Eckler: Gonna go with choice C.
Sam: It is C, sir. Well done.
Downregulation of GABA A receptors and upregulation of NMDA receptors
is actually the physiologic mechanism by which alcohol has its use.
And chronic use leads to an increase in both of those things, which means
you have a downregulation of your suppressive activity and an upregulation
of your NMDA excitatory receptors which is all great if you've got
alcohol in your system all the time.
But then when that alcohol's gone, we have some problems.
And those problems lead to the presentation in the ER.
and there is a great table as always, on page five, discussing the differential
diagnosis of alcohol withdrawal, which by the way is pretty broad, and that
is primarily due to the fact that alcohol withdrawal symptom presents
with tachycardia, with hypertension with tremors and with multiple system
involvement and multiple vital sign abnormalities, which you can get from
multiple other things like drug ingestions from sympathomimetics, antimuscarinics,
sedative hypnotic withdrawal, severe alcohol intoxication, interestingly,
will look like severe alcohol withdrawal.
And so sometimes it can be difficult to tell.
And serotonin syndrome, all of those toxicologic diseases
should be in the differential.
And then you've got some other medical things like thyrotoxicosis,
encephalitis, acute psychosis.
So if they're having active delirium and visual hallucinations,
it can be hard, especially if there's a psychiatric history.
Hypoglycemia, head trauma, and sepsis and septic shock.
So lots of disease processes, especially pretty serious ones
that can mimic that presentation.
And things to keep in mind when you're suspecting someone has
alcohol withdrawal symptom.
And when we talk about our pre-hospital colleagues and what they can do
there was a pretty good section here.
I really enjoyed reading the description of all of the things that our
pre-hospital colleagues are already doing.
So one of the biggest thing is rapid transport to an appropriate facility.
And when discussing that, the author was quick to point out that about 40%
of all ED visits for alcohol related complaints arrive by ambulance.
So, you know, a bulk of the population is coming by EMS and that the
presence of markedly abnormal vital signs or severe agitation prompts
pre-hospital personnel to transport the patient to a medical facility
rather than a psychiatric facility.
Because in many areas we have sobering centers or places where
EMS can take somebody to sober up if they're thought to just be alcohol
intoxicated which are wonderful.
There's good evidence behind those facilities that they are appropriate
and that they can reduce ED utilization.
In fact, the data suggests there was a 2019 review and found only
4% of patients got transferred from sobering centers to the ED.
So that means 96% of the time we're getting that decision right.
So that's a very important distinction that our pre-hospital
colleagues have to make.
And when they figure out, Hey, this person needs to go to the medical
side, then there is some therapy they can initiate on the way to the
hospital, specifically benzodiazepines, depending on what they're carrying.
So IM midazolam, collecting information about possible ingestion or co ingestions
or drug utilization from the patient or from other people who are on the
scene trying to see if they see obvious evidence for drug paraphernalia there.
All of these things become very, very important and then measuring that mental
status and how it changes over time.
So depending on how long the transport is, they can get a little bit of time with
the patient and trend their mental status.
And so by the time they get to the ED, if they're floridly confused but didn't start
that way, that can be an important clue.
So lots of things that our EMS personnel can do to help us in not
only gathering information, but helping decipher exactly where they should go.
Whether that's a sobering center or an ED,
T.R. Eckler: Have you ever worked somewhere that had a sobering center?
Sam: I kind of thought that one of the pods in our emergency department
was the sobering center for a while.
T.R. Eckler: I think having just worked Halloween where we did reopen
one of the pods to become a sobering center, I would tell you that
that's not an inaccurate assessment.
But when I was in Denver Health doing my away rotation in medical school, they had
one of these for Denver Health, and it was such a refreshing thing to be like,
wait, you can just send the intoxicated patients that look pretty good somewhere.
And they were like, yeah, you can just send them all out.
Like they just go over to the sobering center and then a couple will come
back, but most of 'em are fine.
And it was just such a great way to decompress your ER, especially at
like those peak evening kind of times.
It was a well thought out and highly effective intervention
from what I remember.
Sam: Now, in that area, they went to the Sobering center from the ED.
So they came to the ED first, and then you decided if they could go.
T.R. Eckler: And, or they could go straight there.
It kind of depended on who brought 'em in and things like that, but it was an
option from the ER to move them to there.
And I, I thought it was just one of those neat ways to kind of
help you move through the volume.
So it was a positive experience.
And then I just wanted to highlight how much I appreciate.
I think IM midazolam is just such a great choice for these patients
in the prehospital setting.
'cause I think that giving longer acting benzos sometimes to these
patients will kind of cloud the picture for a longer period of time.
Whereas I really like when I get a short term control from EMS and then
they come in and I can kind of get a sense in the first hour or two as to
where they're going as opposed to like, that starts to sneak by me and then
it's a couple hours later and maybe they're getting admitted for something
and then stuff starts to wear off.
So I always really like when pre-hospital people can give more
short acting things if they can.
Sam: Yes, yes, absolutely.
And I'm sure the pre-hospital people like it as well.
IM Midazolam is a great drug, works super fast intramuscularly and as you
said, is short acting, kind of the ideal agent for pre-hospital setting.
And then when they get to the ED and it's time to obtain our history,
assuming we can get it from the patient.
Table two on page six is a great summary of the kinds of things that we
want to know when we're interviewing somebody to decide if they have risk
factors for alcohol withdrawal syndrome.
Like have they personally had alcohol withdrawal syndrome before?
That's probably the most important question to ask.
But also, is there a family history of it?
Do they have any known metabolic derangements, liver problems, cirrhosis?
Do they have a history of thrombocytopenia that kind of
goes hand in hand with cirrhosis?
Also important to ask when their last drink was, how
much did they normally drink?
Have they ever had withdrawals in the past, and how severe were they?
Did they result in an ICU admission?
Did they have true delirium tremens?
Did they have visual and auditory hallucinations?
Have they ever had withdrawal seizures?
All those are very, very pertinent questions to ask.
And if for some reason you're able to elicit that they have stopped drinking
or cut back on their drinking, you really have to follow it up with a
question about why that's the case.
If they want to stop drinking, that's fantastic, but if you forgot to ask
why, and it turns out they have severe epigastric abdominal pain and acute
pancreatitis, and that's why they stopped drinking, that's an important
piece of information to elicit as well.
T.R. Eckler: This is such a patient population that I just
have more questions always
When I try to teach students about this, I'm like, you know, 1% of the
time they've just decided it's time and they've decided to stop drinking the
other 99% of the time, there's some other reason and you really wanna know that.
'cause it might be pancreatitis, it might be a GI bleed.
It might be because they started really going into DTs and they realized that
things were getting worse or they got into something else like a toxic
alcohol or they overdosed or something else has happened that has interrupted
their normal pattern of behavior.
And you need to have just the highest level of suspicion 'cause these are
people that are not doing something that is respected and they're going to always
be trying to hide it and minimize it.
So the more that you can develop that rapport with them and try to really like
establish the trust and try to establish as much that you're there to help them.
And then gradually build to where you ask about their use
and you ask about their history.
And I think something that I learned too is how much more common the tactile
hallucinations are than the visual ones.
I'm not asking enough about if you feel something like that, because
I feel like everyone's got worms and bugs in the ER these days.
But I think this is something where I'm gonna try to tease that more
delicately from these patients to see if I can catch earlier which ones
are actually heading for DTs and need to be looking at like an ICU stay.
Sam: And, you know, I always found that my patients fell into two categories.
Those who were completely in denial or were still trying to hide it from people.
And so they were minimizing how much they drink and those who were just
completely open about everything, I could just say, how much do you drink?
They would be completely upfront.
And I'd say, have you ever had procedures before?
Oh yeah, I've had three and I've been at ICU once and I've
been to detox a hundred times.
And then I would always follow it up with, you know, do you want to go back today?
Is today the day?
And sometimes people would just say, no, no, I'm gonna go right
back and start drinking again.
I go, okay, so we're not seeking detox today.
Like, nope, no, not at all.
And sometimes people would say yes, you know, I've been there a hundred times.
Today's gonna be 101.
I'm hoping it's gonna be the time that sticks.
And that's important to differentiate.
So don't be afraid to just be blunt and ask those questions.
It doesn't have to be accusatory.
Just 'cause you're asking.
T.R. Eckler: I also think that this is also more of a history
piece than more of an exam piece.
So I wanna move this forward in the discussion, but I think it's important
to ask about other medications they're using, because I find that
in other populations I'm more worried about, are you taking propanolol?
Are you taking labetalol or metoprolol?
Are you taking something that's gonna, you know, like slow down your heart rate?
And these are patients that are, because their alcohol abuse are gonna be more
prone to AFib, they're gonna be more prone to having other medical problems.
And if they're taking a beta blocker or if they're taking clonidine or
tizanidine or guanfacine that's gonna blunt their withdrawal symptoms and the
appearance of their withdrawal and kind of dampen the things that are gonna make
you think that they're getting worse.
So that was something that I took away from this, that I needed to be more
cautious of, to make sure that this wasn't someone that I was hiding their symptoms
by having other medicines in their tank.
Sam: yeah, yeah, exactly.
We're not, covering up alcohol withdrawal because we forgot to ask about medications
that might blunt some of those symptoms.
Alright.
Couple more questions.
Which of the following statements about Sobering Centers is accurate?
So they provide long-term detox programs.
They are appropriate for patients with severe withdrawal.
They manage medical complications of alcohol withdrawal.
They typically monitor vital signs and offer referrals.
And they require inpatient admission orders?
T.R. Eckler: It's D. I love them for that.
Sam: That's right.
That's right.
They do a great job.
They're monitoring vital signs.
So yes, they're doing that and they're offering referrals and they're there
literally just to keep someone until they're sober enough to go home.
They're not there to treat alcohol withdrawal, but they do provide
a good service and they do offer referrals to patients for sure.
All right, one more question.
What is the most predictive risk factor for developing
alcohol withdrawal syndrome?
So when they're there in the ED and we're trying to figure out, okay, what's your
risk for alcohol withdrawal syndrome?
What's the most predictive risk factor?
A blood alcohol level on arrival greater than one 50 B, a history
of alcohol withdrawal seizures, C, low serum potassium, D male
sex, or E use of antidepressants.
T.R. Eckler: My experience on Halloween suggests that male sex
is concerningly close to the truth.
But I think that this is, if you've previously had alcohol
withdrawal and seizures, that is the most predictive factor.
I
Sam: Yeah.
T.R. Eckler: Found that the discussion in the article about kindling that
basically the more you feed the fire, the harder it is to get it under
control was very apt for these patients.
And I, I really did think it characterized some of these people that they're really
kind of burning through themselves and drinking harder and harder.
And you need to be aware that they're gonna need more and
more benzos to control 'em.
So you need to be ready to escalate and get more aggressive.
'cause they come in months later and they may be significantly
more ill than they were before.
Sam: Yeah.
Yeah.
You brought up a great point there to this point about kindling, meaning that the
more times that someone cycles through a severe alcohol withdrawal and then
medical treatment and then goes back to drinking and then comes back again in
alcohol withdrawal, this cycle actually makes it more difficult in subsequent
episodes to treat their acute alcohol withdrawal and they end up needing
escalating doses of benzodiazepines.
So if you have an EMR that allows you to look back at prior admissions and see what
they used last time, that's not enough to judge what they're gonna need this time.
Just know that it's a very good possibility they'll need more this
admission than they did during the previous admission, especially if there
have been multiple prior admissions.
So that was a great point in the article.
And also 'cause I like figures and tables.
Figure one in the article on page six for alcohol withdrawal syndrome, the timeline,
which I thought was very helpful.
You've got the green timeline, which is six to 12 hours where they're just
symptomatic headache, anxiety, maybe some nausea and vomiting and some
abdominal pain, palpitations and tremors.
And then once you get past 12 hours, that 12 to 36 hour range has
worsening tachycardia, increasing blood pressure, maybe seizures,
maybe agitation, maybe fever.
And then finally the worst case in the red zone, 36 hours to a week where
they get the true disorientation, the altered mental status, the
hallucinations and the delirium tremons.
So kind of three buckets to put your patient in depending on
when their last drink occurred.
and kind of helps gauge who you think is going to be able to go where, depending
on how far on the spectrum they are.
T.R. Eckler: don't put too much faith into the answer as to when exactly their
last drink was, because much like the last time you used opiates, I'm not sure that
they're regularly going to defer to giving you the honest truth in these cases.
Sam: Yeah.
Not to mention the fact that, you know, in order to tell you when their
last drink was, you have to know what time it is now and what day it is.
T.R. Eckler: Or what time it was then
Sam: Exactly.
T.R. Eckler: Because you might have passed out
Sam: Exactly.
T.R. Eckler: It's not something that I put a lot of faith in.
I'd say, okay, alright, we'll kind of see how it goes.
Sam: Fair enough, fair enough.
When it comes to physical examination, there are some things
you're gonna be looking for.
Tremor, nausea, vomiting, hallucinations, psychomotor agitation, anxiety,
seizures, and autonomic hyperactivity.
Those are all the DSM five TR criteria.
And that's not TR as in TR Eckler, by the way.
That's TR as in text revision.
So.
T.R. Eckler: Do you feel like I've seen enough of these patients to
have a scoring scale of my own?
Sam: You might, you might.
T.R. Eckler: I was alarmed though that the DSM five said that you only
need two of the eight to qualify because that seemed just about as
broad as usually is with these people.
All alcoholics can kind of fit into the withdrawal picture
if they try hard enough.
Sam: Yes, yes, yes.
That makes it very, very likely that they're gonna fall
into that bucket for sure.
Now that doesn't tell you where they are on the spectrum.
That just tells you that they have enough elements to get the diagnosis,
alcohol withdrawal syndrome, and then there is a good discussion
there about scoring the severity.
So this is interesting.
I actually had a recent debate with some emergency physicians
about this particular issue.
When we talk about the CIWA-AR, so this is the Clinical Institute Withdrawal
Assessment of Alcohol Scale revised.
So that's the CIWA-AR, or Alcohol Scale Revised.
And it's a questionnaire.
It's got several questions on here, just asking about everything from
nausea and vomiting and tremors and sweats to anxiety and agitation.
And then the disturbances, tactile disturbances, auditory
disturbances, visual disturbances headache, and then orientation.
And some of these are objective, some of these are very subjective 'cause
you're asking them or you're just kind of interpreting them yourself.
And depending on where they score, they can be mild, moderate, or severe.
So less than 10 is mild, 10 to 18 is moderate, and more than
19 or 19 or more is severe.
And that becomes helpful for a number of reasons.
Now, the debate I had with the emergency physicians we were
talking to was, who does this?
And whether or not this is required, it's obviously not required to make the
diagnosis of alcohol withdrawal syndrome.
You don't have to have a specifically high or low CIWA to make the diagnosis.
But it is helpful for monitoring the progression of their symptoms or
hopefully the improvement of their symptoms, their response to therapy.
And for anybody you're gonna hand off the patient to, so if you're gonna admit them
to the inpatient wards or the OBS unit, one of your colleagues, or the ICU, it's
important for them to know where this person started, where they are now, and if
they're improving with what you've done.
And there has to be some kind of objective measure for that.
And honestly, a lot of times our nursing colleagues are the ones
who get stuck having to do this.
And this can be done, you know, once every hour, once every four hours.
It just depends on how sick the person is and what your protocol is.
But it's helpful to have something documented.
And also as is always the case, when there is something documented, it
ends up getting kind of eaten up by our coding and billing colleagues.
And so many insurance companies will use an initial CIWA score to justify
an OBS versus an inpatient payment.
And so even though it may be something your nursing colleague did and you
documented something far worse, if your nursing colleague documents a very
minor CIWA score, this person may end up just reimbursing at an OBS level.
And so it does have some repercussions but it is also clinically helpful, especially
if you're gonna trend ongoing therapy.
T.R. Eckler: I think, not to jump the gun, but I think that there's value
here when you're looking more at giving longer acting, you know, less
exhilarating benzos, or when you look at a drug like phenobarbital, because
I think that patients are gonna be more likely to give you an honest
assessment if they know there's not a mountain of Valium coming their way.
So I think that there's more value here if you can get kind of a gradual
control of the patient's symptoms with something that's longer acting and less
of a euphoric high kind of creating.
Did you look at any of the other scoring systems they have out
there now like they suggested here.
Sam (2): Yeah, there is two others that the author mentioned, The BAWS
or the Brief Alcohol Withdrawal Scale and the PAWSS or prediction of
Alcohol Withdrawal Severity Scale, all three of which are on MD Calc.
T.R. Eckler: I thought BAWS and CIWA both had the potential for, if you were the
patient and you wanted to really enhance your symptoms, everything could be a 10
outta 10 or a seven outta seven I guess.
'cause most of them are scored outta that.
But I really liked the PAWSS 'cause I think that it's a good way of
saying, Hmm, you know, this is the alcoholic patient I got, what's
my level of concern about them?
Do I think they need ICU or step down or the floor?
I thought this was a cool tool that I think is gonna help me land patients more
appropriately in the right level of care.
'cause I think it's gonna tease out some of the higher risk patients
that I don't think I'm necessarily asking all the right questions to.
Sam: If you're concerned or want to see what a CIWA looks
like, it's there on page eight.
There are a number of resources online where you can just download
this form and print it or put it in a digital form and incorporate it in
your EMR if it's not already there.
It's probably the one that is the most widely studied and has the
biggest body of evidence behind it, and that's the CIWA-AR.
The others like you mentioned already there are some in MD calc, the SEWS or the
SEWS severity of ethanol withdrawal scale is not on MD calc, but the other two are.
There's not as much evidence for those in the ED, but that
doesn't mean they're not helpful.
Just pick one, have something that is consistently used.
It is more helpful for everyone to use the same one than it is for you
to use one and for your inpatient colleague to use a different one.
So there may have to be some compromise there, but the point is having some
kind of objective or pseudo objective measuring scale is helpful because it
helps guide your therapy especially if you're gonna be doing symptom management
based dosing as opposed to just a set schedule dosing for medications,
which we'll get into in a second.
T.R. Eckler: I would also just add, I think that it's tricky to
really assess hand fasciculations.
I think that sometimes it's convincing, but sometimes patients
are trying to either enhance it or they're trying to cover it up.
They're trying to kind of do one or the other.
I find tongue fasciculations to be a lot more reliable 'cause
it's a pretty hard thing to do.
And I'll often ask patients to do it together.
I'll be like, hold out your hands and stick out your tongue.
And they're used to it being hands, so they won't think about their tongue.
And I find that that gives me a kind of cleaner indication of how ill
they are and how I'm doing in terms of controlling their withdrawal.
Sam: Yeah, great points.
There is an entity called Complicated Alcohol Withdrawal, and that's really just
as things are progressing and your alcohol withdrawal now encompasses hallucinations
or seizures and you're being diagnosed with delirium or delirium tremons, those
are encompassed by the global diagnosis of complicated alcohol withdrawal.
And then there is alcohol withdrawal.
Hallucinosis which again is kind of, we're just working
our way up to delirium tremons.
So this is hallucinations, visual, auditory, or tactile.
More frequently tactile, less frequently, auditory and even less frequently visual.
And this is anywhere from one to 12% of patients, depending on how sick
the population is, you're admitting.
But they get this altered sensorium and this eventually progresses to
full-blown delirium tremons if untreated.
And then there is alcohol withdrawal seizures, which we've talked about
on the podcast before when we talked about status epilepticus.
It's a pretty rare complication, less than 3% but it can occur and the treatment here
is always benzodiazepines and not really the standard anti-epileptic medications.
They don't tend to do a good job in this kind of scenario.
Patients with alcohol use disorder are at increased risk for lots of CNS conditions.
So this is the rub, including infections, subdural hematomas, metabolic
derangement, and drug ingestion.
And so even though they're coming in seizing with a history of alcohol use,
it can be difficult to say for sure this is alcohol withdrawal until you've
excluded all of those other things.
Just keep that in mind.
T.R. Eckler: I think the caution is when you are having trouble controlling them.
So you've given a couple rounds of benzos and they're still having seizures.
I've had patients like this that now it's trauma, now it's a
subarachnoid, now it's a poisoning.
Now it's hypoglycemia.
So you need to keep kind of moving the gears.
'cause EMS will come in and say, ah, this is an alcoholic.
We know him.
He gets seizures.
And you've gotta keep that high level of suspicion that you know, they're
sicker than they usually are, or there's a problem I can't control.
So it's gotta be something else.
So I find that the CT scanner and more labs and more workup
is your best friend here.
So keep following your gut.
Sam: All right, and on that note, another question.
A 52-year-old man is brought to the ED altered diaphoretic, grasping
at the air he was last seen four days ago for alcohol intoxication,
what is the most likely diagnosis?
Is it alcohol intoxication?
Alcohol withdrawal, hallucinosis?
Is it delirium tremons?
Is it schizophrenia or is it Wernicke's Encephalopathy?
T.R. Eckler: I tell you that he could be just hallucinosis or it could be
heading towards delirium tremons.
I would start with hallucinations, but I would have a high index of suspicion
that we were heading there too.
Sam: Yeah, so you're correct.
The answer, the technical answer is delirium tremons, but delirium tremons
your manifestation is gonna be delayed.
So he was last seen four days ago for alcohol intoxication.
If he hasn't had a drink since then, it takes about 72 hours to push
you into that red zone where you're in full blown delirium tremons.
Your hallucinations are gonna start right around 36 hours and so he is somewhere
on the verge of delirium tremons.
But yes, I will take alcohol withdrawal hallucinosis because right at 36
hours is when that's gonna begin.
And either one of those could be complicating this presentation.
And on that note, let's talk about diagnostic studies, specifically labs.
So this isn't gonna be a major surprise to anyone.
We order a bunch of labs in the ED.
So you're gonna get your routine labs, so your CBC your
chemistry, your renal function.
It is helpful to get coagulation studies if you know they have a
history of cirrhosis or if they look like they're cirrhotic because that
can help you gauge how far along in their liver disease they are.
You should expect to see things like thrombocytopenia
and anemia and leukopenia.
So, low white blood cell count, low hemoglobin, low platelet count in your
chronic alcoholics is pretty common.
You can actually get an elevated white blood cell count from things like alcohol
withdrawal seizures but just know there's a lot of overlap here with other diseases,
so you can't rely on that for anything.
But there are some things that are common.
An alcohol level is also helpful, especially if there's any question
about whether or not the person's intoxicated versus in true withdrawal.
There are chronic alcoholics who will begin to withdraw long before
their alcohol level reaches zero.
So we've all seen those people, we know them well, and that's treated clinically.
So don't be afraid to begin the benzos early or if they're gonna go home, you
know, discharge them as soon as they're clinically sober so that they don't
withdraw in your emergency department.
And then testing for co-ingestions.
So aspirin, Tylenol a drug screen, which you know, is universally not
great, but better than nothing can sometimes tell you if there's some
sympathomimetics on board, some cocaine, some amphetamines, anything else that
might be altering their vital signs.
So all of that is helpful.
An EKG is very helpful especially if they have severe electrolyte
deficiencies to take a look at their QT intervals, because things that
are seizures or things that look like seizures may not always be seizures.
And so you can get arrhythmias that's pretty common.
Atrial fibrillation probably being one of the most common.
And then there's imaging.
So chest x-ray is indicated if there's hypoxia or fever or
any kind of chest discomfort.
CT imaging of the brain is certainly indicated if they have alterations
in their mental status or seizures or evidence of head trauma.
And so those are probably pretty routine for most of us
in the emergency department.
T.R. Eckler: Any suspicion for trauma?
I would say I'm adding a CT of their cervical spine to that as well, because
I've seen plenty of those kind of traumas where they've got multiple injuries.
And then I think this article convinced me I need to be thinking
more about an ammonia level.
I think that more of these, you know, sicker, older alcoholics, I
need to be aware that their liver can be failing and there can be some
degree of hepatic encephalopathy.
So I think that's something to help my colleagues upstairs as
to give them a starting point as to where their ammonia level is.
Sam: Yeah, for sure.
Point of care glucose is another one.
You know, we mentioned hypoglycemia but they can get alcohol ketoacidosis and get
pretty significant acidosis and you're gonna give 'em fluids and then you're
gonna give them IV D 10 or infusions of some kind of glucose solution.
And you wanna give them the thiamine.
And so when we get into the meds, we'll talk about all of that, but just know
that those are pretty common derangements.
We're gonna see hypo mag.
If there's not a magnesium included in your chemistry profile, you're
gonna want a magnesium level.
So it's not a sparing approach to testing for this patient population.
T.R. Eckler: I really try to look at their anion gap because if there's
really a metabolic acidosis there and it's significant, and I don't think
it's because of lactic or I don't think it's because of alcoholic ketoacidosis,
then is there a toxic alcohol there?
And I think this is a group that I'm always trying to catch, like did they
get into something else while they were drinking and is there something else I
need to be worried about that they might need, you know, dialysis for or something
to clear because the earlier you get to that answer, the better it's gonna be.
So I try to keep that high index of suspicion for, we're looking at labs
for these patients to really kind of see what it looks like and then
considering further workup or talking to poison control if I've got concerns.
Sam: All right, let's get into treatment.
So we talked already about that kindling effect, where repeated cycles
of withdrawal and intoxication kinda heightened their CNS hyperexcitability
and cause longer duration and severity of withdrawal symptoms.
And so they may need escalating doses of medications.
So be alert to the fact that this may not be their first presentation.
the really mainstay of treatment here is decreasing overall stimulation.
'cause this is what the alcohol was doing before it went away, and this is
what their brain has been accustomed to.
And the mainstay for doing that is still benzodiazepines.
And we'll talk more about other options here in just a second.
But the benzodiazepines are well studied.
There's a good volume of evidence behind them, especially in this population.
Not necessarily specific to one agent.
It started back in the 1960s with chlordiazepoxide.
This is oral Librium therapy.
And so there's a large volume of evidence behind that particular therapy.
T.R. Eckler: OG Baby.
Sam: Yeah.
T.R. Eckler: Nobody ever asks for a refill on Librium.
It works and it isn't awesome.
Sam: It, it does very well.
The other benzodiazepines in this category include things like diazepam,
which is rather long acting with a half-life of 20 to 80 hours.
Lorazepam, which is much shorter acting 10 to 20 hours.
Midazolam, which is the shortest acting, that's six hours.
And then chlordiazepoxide, which is anywhere from 24 to
84 hours, but is oral only.
And so those four benzodiazepines make up the bulk of therapy, and there are
multiple ways to go about doing this.
I like that the author recommended a pretty liberal approach to medicating
patients, especially as they first start to develop symptoms, kind of getting on
top of them early, not having to wait until they're in full blown withdrawal
because then you're catching up and somebody who might have even been able
to go home is now stuck maybe having to go inpatient or even to the ICU.
So it is important to recognize it and recognize it early.
Nowadays in the era of medication shortage, you may not have the
luxury of deciding between these agents, and so just know that the
chlordiazepoxide is oral only.
So that leaves you with only three IV options, midazolam,
lorazepam, and diazepam.
And if given the option between the three diazepam is the longest
acting, but also has some hepatic metabolism that has to be occurred in
order to clear it from your system.
So if you've got somebody who's cirrhotic, it's gonna be on board for
a little longer maybe than you intend.
Lorazepam does not undergo the same hepatic metabolism.
It only undergoes the phase two hepatic metabolism.
So it's gonna be eliminated mostly by the kidneys and it
may be more reliable for dosing.
Midazolam works great for IM, if you don't have an IV yet, and
we've already mentioned that.
So there are some nuances to medications, but by and large it's gonna be,
you know, what do you have and what do you have in large quantities?
Because depending on how sick they are, these patients can take anywhere from like
triple digits to four digit milligrams.
We're talking about grams of medication to get symptomatic control.
And over the course of days in the ICU, they run through
massive quantities of medication.
And so when it comes to benzodiazepines, it's going to be give it, give it
early be liberal, but know that yes, there are some side effects.
You know, sedation probably being the one people worry about the most.
But it's not a reason to withhold therapy by any means.
T.R. Eckler: I would say the state in our shop right now is such that we only
have versed, we have very, very limited, if not non-existent supplies of Valium
and Ativan or diazepam and Lorazepam.
So essentially we're, you know, giving Midazolam when it's indicated, but then
we're moving to oral or other strategies like our next topic of Gabapentin because
there's just such a need to preserve our benzo supply of what we can to have
it not just for these patients, but for our patients with agitated delirium
or other patients that need sedation or for our pediatric seizure patients.
Sam: Yeah, great point.
And there are some shops that have converted to phenobarbital exclusively.
It's just their first level medication that they're giving
initially, and they're not even discussing benzodiazepines anymore.
And we'll get into that in two seconds.
First, a trivia question, in which situation is Lorazepam
preferred over diazepam for treatment of alcohol withdrawal?
In patients with mild withdrawal symptoms, in patients requiring IM medication, in
patients with end stage liver disease, in patients with a history of epilepsy,
or in patients with hypotension.
T.R. Eckler: C you don't want to give it to the cirrhotics.
Sam: That's right.
That's right.
Only because lorazepam, like I said before only has phase two liver metabolism
while diazepam does have to go through the full liver metabolism and it can
hang around a lot longer than intended.
Again, if that's all you have, don't withhold it because of that.
But if you have the luxury of choosing between the two and you know the
person has end stage liver disease, you're headed for the Lorazepam.
All right, let's dive into phenobarbital.
So phenobarbital has been around for a very long time and it is a
medication that was used for alcohol withdrawal, then was kind of dropped
and we went to benzodiazepines and now it's kind of making a resurgence.
It's in the category of medications called barbiturates and it has a distinct
binding site on that GABA A receptor.
And it increases chloride influx.
And I don't wanna get too deep into the physiology of it,
but just know that it works.
But it works by a secondary mechanism, so it has a different pathway
than your typical benzodiazepine.
And it can result in symptomatic control for much longer periods,
we're talking like half life of 120 hours, and the tapering
effect from a single loading dose.
And so you can get more or less what some people have described, ideal
alcohol withdrawal coverage that lasts multiple days and then gradually tapers
off without having to give somebody a prescription for a Librium or give
them multiple doses of benzodiazepines.
You can just load them once and then as soon as they're clinically
sober, discharge them home.
And many centers have converted to that as being their first line therapy.
You use much phenobarbital?
T.R. Eckler: This is the biggest change in my practice in the last five years.
I would tell you that because of shortages and because of just the
severity of some of the patients that we've seen and the fact that now I'm
not transferring them out, they're staying in my shop compared with like my
rural times where a lot of times these patients would be getting transferred.
I am giving a lot more phenobarbital, both for patients getting admitted
and patients that are getting discharged because as you said, I
think it gives me guaranteed control.
It really stabilizes the patient in a really reliable way.
And it doesn't preclude you then from giving other medication on top of
that, whether that's a little more phenobarbital or benzos or something else.
But it's gonna decrease the total amount you're gonna need of
anything else by a dramatic amount.
And I think that, especially when I'm, you know, admitting to a very
busy hospital, the hospital's full.
I'm worried when the inpatient team is gonna get to some of
the patients or this or that.
I find that taking control of these situations is with the phenobarbital
load in the emergency room, especially given that we have great ER pharmacists
that help us to administer it it's a great tool to have and it has
completely from when I was in residency and in the rural places to now I've
completely gone a 180 on it because I used to say, ah, no, I'm a Valium guy.
I'm from New York City.
That's what we do, and now I really have started to lead with this more and more.
I find it especially really helpful in the kind of patient that's, you know,
not sick from alcohol, but sick from something else, like say an aspiration
pneumonia or COVID or flu, and they're a little hypoxic and they look unwell.
Giving them a loading dose of phenobarbital often stabilizes them in a
way that gives them a chance to like cool off and calm down without you constantly
debating of, should I give this patient benzos when they need oxygen already?
I'm worried about the oxygen demand getting worse.
It gives you a chance to treat one problem and then move on and focus
on the next one, and then if they get worse, you know that it's because
that's what you need to work on.
Sam: Yeah, that's perfectly said right there.
there is some evidence behind phenobarbital.
There's very little comparing head to head phenobarb versus benzodiazepine.
So there was one study cited by the author a prospective
randomized trial, 44 patients.
So very small comparing lorazepam to phenobarb and it showed no difference in
the mild to moderate alcohol withdrawal syndrome as far as admission rates.
Follow up CIWA scores at 48 hours from discharge.
That at least is one comparison study.
There's lots of clinical anecdotes.
There was one meta-analysis of 12 studies, so that's a total combined
population of almost 2000 patients that compared benzos to phenobarbital
and showed there was no differences in the rate of intubation, seizures,
hospitalization, and ICU length of stay.
But also there are now some double-blinded, randomized placebo
controlled trials that compare benzos only to benzos plus phenobarbital.
And found that those treated with phenobarbital had significantly lower
rates of ICU admission compared to placebo, but also highlighting that if
they had phenobarb plus benzodiazepines, they fared better than just benzos alone.
So it is now something that is being recommended as a reasonable alternative
by a lot of clinical practice guidelines.
The ASAM, A-S-A-M, the GRACE four trial and recommendations, and
the Society for Academic Emergency Medicine, all of them are recommending
these as potential alternative therapies or adjuncts to first line.
So you can certainly replace them if you're comfortable or if that's become
the standard protocol in your shop.
Great.
Just make sure that you have some kind of protocolized approach and that you
know, everybody's on the same page.
That yes, this is what we're doing.
The loading dose is 10 milligrams per kilo IV given over about 30 minutes,
T.R. Eckler: That's ideal body weight though.
You gotta make sure you're basing it off their ideal body weight because not
everyone is at their ideal body weight.
Sam (2): I have no idea what you're talking about, sir. Yes,
thank you for that correction.
10 milligrams per kilo of ideal body weight, or you can give 260
milligrams IV over five minutes for moderate symptoms, just as a
one time non-weight based dosing.
And then subsequent dosing can occur every 30 minutes as
needed until you get symptomatic relief up to a gram in 24 hours.
So you can get pretty high doses.
And the most important thing to remember is that this is a
kind of a one and done thing.
Once you get them loaded and they've achieved control they're
good for up to 120 hours.
So you know, if they have appropriate control of symptoms, normal vital
signs are awake and alert and aren't really sedated by this medication.
This is somebody who could go home.
Somebody who you would've previously given a prescription to for Librium
and said, this is how I want you to taper over the next few days.
This kind of is on automatic taper as they metabolize it, and they
don't have to worry about it anymore.
The patient does have to be reliable.
You know, they're supposed to not go and drink alcohol during this time
period, just like they would if it was Librium or some other benzo.
So you do have to select your patient appropriately.
And know that the typical side effects for phenobarb are pretty much the same
things you're gonna get from benzos.
We're talking respiratory depression and over sedation.
It does have kind of a narrow therapeutic window, which means there's a little
more rapid progression from, you know, normal to sedated as you're giving it.
But once you get used to it and you've become someone who uses it more frequently
you'll get comfortable with that dosing.
And a protocolized approach is really the best way to go.
T.R. Eckler (2): 10 milligrams Per kilogram ideal body weight over 30
minutes is what we're using in our shop, and I've had tons of success with it.
I find that sometimes then afterwards, if the patient's still a little anxious, I'll
give them a little bit of Valium as well.
'cause sometimes I think they think they need it.
But I think once you let this really kick in, the patients do great.
I think my one caveat for these patients is you don't wanna use this in that
really sick, really altered, you know, delirium, tremons patient if you really
think they're heading for the ICU, because I think that those kind of patients you
might wanna consider propofol, precedex, something that's a little more short
acting that you can adjust more carefully.
And I've gotten support for that from my ICU colleagues.
I think that kind of varies from shop to shop.
So I think that's worth a discussion between the ER and the, you
know, medicine and the ICU teams.
But I think that that's an area that we're still trying to work out kind of exactly
which patients do best with phenobarbital versus precedex versus propofol and benzos
and kind of what the right mixture is for the really, really sick patients.
Sam: Yeah.
Yeah, that's another great point.
If they're already headed to the ICU and you're not trying to just prevent
that, then certainly a conversation with your intensivists about what
their preferences are is due in advance of the patient presentation.
There are some adjunctive therapies.
So we mentioned thiamine.
All of these patients are going to be, you know vitamin deficient and are gonna
need thiamine, and most of them are gonna end up on some kind of glucose solution.
The ideal timing is to give the thiamine first.
But if they're hypoglycemic, you're not gonna withhold the glucose in
order to give them the thymine first.
You could certainly start it and then give the thiamine and it's okay to
give them simultaneously as well.
So they're definitely gonna be thiamine deficient.
The standard dose is a hundred milligrams IV, but if they have
symptoms like nystagmus or ataxia or confusion, those are the symptoms
of Wernicke's encephalopathy.
Most people will have not all three of these.
So you know, only 10% of the population who actually has Wernicke's encephalopathy
will show all three of these.
But that's kind of the, the textbook triad nystagmus, ataxia and confusion.
If they are already presenting with those, then you're talking about larger
doses, like 500 milligrams IV of thiamine.
But the standard dose is a hundred IV and you give it hopefully before
you start your dextrose solution
T.R. Eckler (2): I've had one round of high dose thiamine basically
cure a patient right on the spot, like over the course of an hour.
A man came in, just bumbling and really just in a rough state.
And he'd been like that for a few days and his wife just said, well,
I thought he was gonna get better.
And I was like, you know, I really think this is Wernicke's.
And I gave him 500 of thiamine and over the course of an hour or two, he
came around and was his normal self again and talking and everything else.
And I was pretty excited to get him admitted for a couple of days of thiamine
and making sure he didn't progress.
But it was one of those rare moments where the family, looks
at you and goes, what did you do?
And you say, ah, you know, had a thought, had a hunch.
Sam: House MD. That's right.
TR Eckler.
Well done, sir. Well done.
And then the author does talk about like we mentioned before kind of this
risk-based strategy for potentially loading someone in advance of symptoms.
So someone you know is going to withdraw.
You know that they're going to be there longer than they want to be, you know
that they're gonna start withdrawing.
There is benefit shown to starting that benzodiazepine therapy early opposed
to waiting until they're in withdrawal.
So you can then not have to play catchup.
T.R. Eckler: Have a brief moment of we need to modernize something for the
modern age, the cage questionnaire.
I remember being taught about the cage questionnaire in medical school and
I thought it was the judgiest worst questionnaire I had ever encountered.
And I stand by that 20 years later that this thing needs to be changed.
I think we need to sit down and come up with something that's got a better name.
You can't call it the cage.
That sounds like a trap.
'cause it's a trap you gotta come up with something that makes it cool.
It's like that Saturday Night Live skit they did where they was like, you
know, interviewing guys on a podcast is how they do their medical visits now.
Like that's what I think we need is some kind of thing where it's like,
hey, do you like to party great?
How much do you like to party?
Do you need to like, have something to drink after you've
had a big night of partying?
We gotta work on the way that questionnaire works to make it
not seem so much like it's a trap.
Sam: Yeah.
Yeah, that's fair.
T.R. Eckler: I stand in opposition to the cage questionnaire.
Sam: If you're listening, CAGE stands for cut, annoyed, guilty and eyeopener.
And it's a questionnaire that's meant to kinda gauge where they are on their
propensity for alcohol withdrawal because it can affect you know, your
suspicion for alcohol withdrawal or developing alcohol withdrawal syndrome.
And there actually is pretty decent evidence behind the questionnaire and
how early administration of lorazepam in high risk patients on the cage
questionnaire can decrease length of stay.
So it is a helpful questionnaire, but I agree with you.
The acronym does sound a little sanctimonious
T.R. Eckler: There's PAWSS.
I like, 'cause I'm just trying to see how much of an animal you are.
Like maybe you got some big paws.
That's okay.
I'm just trying to make sure that I take the best care of you as I can.
That's what I'm here for.
Sam: right.
On that note, let's move on to anti-seizure medication.
All I gotta say about that is just don't do it.
T.R. Eckler: No,
Sam: It doesn't work.
It does not work.
T.R. Eckler: Unless they have head bleed, then we can talk about it.
Sam: Okay, then you're gonna treat their alcohol withdrawal and they're probably
gonna get dual coverage from that anyway.
But anti-seizure medications uniformly fail when compared with benzodiazepines.
That's a direct quote from the article and pretty much all we need to say about that.
So they don't work well for alcohol withdrawal and not something that
you're going to provide routinely.
Antipsychotics is another one of these things.
It's kind of interesting because people with schizophrenia can be alcoholics.
People who have hallucinations and are on antipsychotics for multiple other reasons
can still go through alcohol withdrawal.
So you can give them antipsychotics if you're treating things that are
not related to alcohol withdrawal syndrome, and that's fine.
You can continue their medications.
But if they're having what looks like psychosis, auditory, visual and tactile
hallucinations from alcohol withdrawal, you're best off going down the alcohol
withdrawal syndrome pathway of benzos and barbiturates and those medications.
And not administering antipsychotics routinely
T.R. Eckler: The way I fall on this is that you've gotta be worried about
respiratory depression in these patients.
'cause you're gonna give 'em a lot of stuff and co administering antipsychotics
and benzos is gonna increase that risk of respiratory depression.
But I also think there's always wisdom in giving the patient their home medication.
And if the patient's on a long-term antipsychotic and you know they're
on it and like, you know, you get 'em a little stable and they're looking
okay, I think there is a place where you give them their home medicine if
they're on a long-term antipsychotic.
But otherwise, I think you gotta be real cautious with this.
Sam: Yeah, yeah.
Well said.
All right.
Let's talk about the intubated patients.
So this is the person who's already going to the unit, and if you're listening and
you've never done one before, you can't do a CIWA score or CIWA-AR on somebody
who's intubated because there are multiple elements there that you can't answer
based on the patient being intubated.
And so the question comes up, well, what can you use?
And the author suggests maybe the Richmond agitation sedation scale
or the RASS can be more appropriate.
This is something we already use for people who are intubated for multiple
other reasons to gauge sedation level.
It's there in table six on page 12, and it includes things like are they combative?
Are they agitated, are they restless?
Are they alert and calm?
Are they drowsy?
Do they have light sedation, et cetera.
And it's a spectrum from minus five to plus four.
And depending on where they are on the spectrum, it can give you information
about whether or not you need to titrate up or down your sedation medication.
So that's a possible alternative for somebody who is intubated
in whom you need to see.
Okay, is my therapy effective enough to reduce their alcohol withdrawal syndrome?
Patients with end stage liver disease.
We already mentioned about the sedation effects and the extra lingering effects,
but just know that there is also a score.
You can score how far along on the liver disease spectrum they are.
This is the MELD or the model for end stage liver disease.
It's in MD calc.
I don't expect you to memorize it, but it takes into account things
like their sodium, their INR, their bilirubin and their creatinine, and
it predicts a three month mortality.
And the high scores can be anywhere from six to 40.
And those are usually the people who have more severe disease.
And that can be a poor prognostic factor for multiple things.
And then the pregnant patients.
So the author is very upfront, Hey, listen, benzodiazepines and
barbiturates have potentially teratogenic effects, but the effects of alcohol
withdrawal on somebody who's pregnant also come with high morbidity or
mortality for both mom and baby.
And so it's it's definitely a line you have to ride, but just
know that a pregnant patient in full blown alcohol withdrawal has
a high risk for this pregnancy.
And so you still have to treat it.
You still have to treat it with these medications.
And if you don't treat it, you're putting the patient at severe risk
for complications like abruption, preterm delivery, and fetal distress.
T.R. Eckler: Make sure they're not going into eclampsia and it's
not their alcohol withdrawal.
'cause it could be both.
So take a look at, you know, their urine and their pressures and things like that.
And don't be afraid to give a mag as well as benzos if you're
just kind of starting there.
Sam: Yep.
Yeah, absolutely.
that definitely gets to be a complicated picture.
All right.
And let's talk about some kind of cutting edge things, right?
So there are some alternative medications that we like to use in the emergency
department, like ketamine, for example.
Ketamine has effects on the NMDA receptor.
We always love to talk about ketamine.
I mean, come on.
it has effects on the NMDA receptor, which is already upregulated in
people who have chronic alcohol use.
So why not use it?
And honestly, there is, some evidence mostly in the ICUs that suggests a
significant difference associated with those receiving sub dissociative
ketamine infusions as an adjunct for decreasing alcohol withdrawal
severity, especially if they're already intubated and already on benzos.
So there is some evidence in the ICU, there's not a big volume of literature
in the ED setting to support this.
So maybe not for the person who has mild to moderate
withdrawal and is gonna go home.
But if they're already intubated and you're already got them on some
kind of infusion and it's not quite having the desired effect, you can
perhaps consider giving them ketamine.
T.R. Eckler: I fall in this one that I like this for the intubated patient
that I'm having trouble controlling their sedation even though I'm
going up on propofol, even though I've given 'em a lot of benzos.
I think this is a nice third line agent there to try to catch the intubated
patient and try to get them calmed down before I get 'em up to the unit.
I think there's a role there and I also think anytime you're intubated you gotta
make sure you're giving 'em pain control.
And I feel like they didn't kind of talk about that, but you always
gotta make sure they're getting something for pain as well.
'cause it's not comfortable to be intubated.
I would say similarly to Naltrexone, I think that there may be a role for
these in the emergency room at some point, but I find that so often I'm
not quite sure where the patient is on their withdrawal spectrum.
And I find that I would worry that I would take someone that was good enough
to go home and all of a sudden make them sick and not good enough to go home.
So I think that there's a great role for these outpatient, but I'm not trying to
use 'em in the emergency room as much.
Whereas Gabapentin, I would tell you may be the second biggest change in my
practice because I find that this is much more well tolerated by patients.
I start 'em in the emergency room with it, and I find that it seems more
successful than the Librium tapers I had been giving before for patients.
And I think it's also less likely to get abused than sending 'em
home with like a Valium taper.
Sam: Interesting.
You thinking about it as a solo or as in addition to?
T.R. Eckler: I would tell you they presented the article as in addition
to, but I'm using it often as a solo thing and I'm finding lots of
success, especially in patients with chronic pain issues or neuropathy.
You know, they're especially ones that do well with it.
But really a lot of people, especially the ones that you know, come in and
they're like, I really do want help.
I think this is a great drug for that because I think they respond
really well to it and you can load them in the emergency room with it.
I don't think I'm loading as high as they recommend here at 1200 milligrams,
but I would tell you 300 to 600, I have a lot of success and then I send 'em
home with a week's worth and really kind of let 'em taper it themselves.
'cause I think that I try not to kind of structure people as much anymore.
Like they have to do this over these days.
I just say, Hey, you're gonna try to wean this down over the next week, and then
if you wanna stop drinking, you can do that after the next week of using this.
Sam: Yeah.
Fair.
The, the article does mention that there's not a whole lot
of evidence for gabapentin.
That doesn't mean it doesn't work, but just we don't have a lot of
randomized placebo controlled trials for this kind of thing.
There is some evidence that there's a significant decrease in
length of stay and total amount of benzodiazepine administration.
The author concluded there wasn't enough evidence to support its use, but, you
know, given if there are confounding variables or other indications for
its use, that it may be beneficial in multiple indications at once.
So still more to come on that, but it sounds like you've had some good
success with it, which is good to hear.
As another option dexmedetomidine is something often used in the
ICU, and again, there hasn't been much evidence around it.
There are some low quality meta-analysis, which really didn't
demonstrate a significant difference in the likelihood of intubation.
Or ICU length of stay.
But again, if they're already on benzodiazepines and your intensivist
wants to use it as a adjunct then by all means , there doesn't seem
like there's any harm to doing it.
Maybe there's not yet a volume of evidence that shows benefit.
And then the last one was Baclofen.
It's interesting one, you know, it does have effects on
gaba B receptor as an agonist.
In 2019 there was a Cochrane review that found some low quality and
insufficient evidence for its efficacy and safety in treating patients
with alcohol withdrawal syndrome.
So really, right now, there's no recommendation to use this routinely.
There are just better options out there.
And lastly is disposition.
So again, it helps if you have a protocol in your emergency department for the CIWA
score because then you can use some kind of, you know, pseudo objective measure
to say, yes, they were appropriate to go home, their CIWA was less than 10.
Or if you have an OBS unit, you can say, oh, okay, their
CIWA's, whatever, less than 14.
And so we're gonna put them in the obs unit and monitor them there.
So having those protocols set ahead of time and using some kind
of objective criteria is helpful to help you guide disposition.
Obviously, if they're sick enough to go to the ICU, that's gonna be
pretty obvious and the CIWA scores is not necessarily going to be
what is the primary driver for?
All right.
Five things that will change your practice.
In summary, front loading and aggressive early therapy for alcohol withdrawal
syndrome can prevent complications and progression of symptoms for sure.
Benzodiazepines are still first-line therapy, but phenobarb is showing
some promising results and both as monotherapy and as an adjunct to
benzodiazepine can be quite helpful.
Third symptom-based treatment is more effective than fixed scheduled treatment
for alcohol withdrawal syndrome.
We didn't actually mention this before, but there are protocols for giving a
flat standard dose every set time period.
That's kind of a fixed dose scenario or protocol.
And then there are those that are symptom-based based on CIWA or
the patient's reported symptoms.
And there is evidence that if you use a symptom-based protocol, you reduce
overall length of stay, patients report better control of their symptoms.
And in general, it's just more beneficial than just some
kind of fixed standard dose.
So tailoring it to your patient is very helpful.
Fourth.
For carefully selected patients with mild to moderate alcohol withdrawal symptoms
managed in the outpatient settings.
Gabapentin can be considered as an alternative or as adjunct
to benzodiazepines, which you already talked about.
And lastly, anti craving medications.
These are things like naltrexone, acamprosate, and gabapentin should
be considered to prevent alcohol relapse in eligible patients.
Of course, if you're already sending them out on gabapentin, then hey, you're
getting two birds with one stone there.
So something to consider, especially if you have a referral program and you know
you're gonna be sending them to follow up with somebody and that's their protocol.
You could say, Hey, I'm sending you to this place and this is what they use.
I'm just gonna start you on it now.
So it's helpful to know what your community resources are.
T.R. Eckler: They did an RCT on Gabapentin and found that the number
needed to treat was 5.4 for no heavy drinking days, and the number needed
to treat for total abstinence was 6.2.
So you're looking at a number that's getting pretty close to like Suboxone, you
know, for our opiate addicted patients.
So I think that this is the same kind of approach you need, where the more
you offer up that opportunity for them, the more often you're gonna
actually land some of these and get some people to actually land in the
right spot and get the help they need.
Sam: Yeah, and if you're listening to this podcast and you're thinking, gosh,
you guys talked about a ton of stuff.
How am I gonna put this all into some kind of pathway or protocol?
Then hopefully you're a subscriber, and if you're not, you should be, because
at the back of this article on page 23 is a fantastic clinical pathway.
It walks you through everything we've just discussed.
It talks about using the CIWA and using dosing based on where they are on the CIWA
score and then ultimately disposition.
And it walks you through everything from assessment through
medication administration, and then ultimately disposition.
Excellent, excellent pathway.
I highly recommend it.
And if you're not a subscriber, you should be because you could then go and get your
four hours of CME credit for listening to this podcast and reading this article.
And that brings us to the end of the November, 2025 article in Emergency
Medicine Practice authored by Dr. Koo.
Thank you so much on the diagnosis and management of alcohol
withdrawal symptom in the ED.
An excellent article.
T.R. Eckler: Great.
Give phenobarbital and Gabapentin a try.
It'll change your mind.
Sam: Yes.
Especially if you don't have access to any other benzos, you
may not have a choice, right?
Necessity is the mother of all invention, right?
Isn't that how the quote goes?
So here we go.
Awesome.
All right, everybody, thanks again.
Until next time.
I'm Sam Ashoo.
T.R. Eckler: TR Eckler.
Excited for another opportunity next month hopefully.
Sam: Stay sober everyone.
See you in December.
And that's a wrap for this month's episode.
I hope you found it educational and informative.
Don't forget to go to ebmedicine.net to read the article and claim your CME.
And of course, check out all three of the journals and the multitude of
resources available to you, both for emergency medicine, pediatric emergency
medicine, and evidence based urgent care.
Until next time, everyone be safe.