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00:00:00,050 --> 00:00:02,480
T.R. Eckler (2): it was one of those
rare moments where the family, looks

2
00:00:02,480 --> 00:00:04,219
at you and goes, what did you do?

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00:00:04,219 --> 00:00:07,509
And you say, ah, you know,
had a thought, had a hunch.

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Sam (2): Hi everyone, and welcome
to another episode of EMplify.

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00:00:12,026 --> 00:00:13,776
I'm your host, Sam Ashoo.

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00:00:13,976 --> 00:00:18,776
Before we dive into this month's episode,
I want to say happy Thanksgiving.

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00:00:18,806 --> 00:00:23,481
It is that time of year again,
and with so much joy I say.

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00:00:24,016 --> 00:00:26,116
Thank you for being a subscriber.

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00:00:26,266 --> 00:00:31,006
And if you're not a subscriber, no better
time than the present eb medicine.net.

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00:00:31,216 --> 00:00:36,286
Get a free $50 Amazon gift card
for spending $300 or more in the

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store and use that CME funding.

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00:00:39,221 --> 00:00:42,341
Emergency medicine practice,
pediatric emergency medicine practice,

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evidence-based urgent care, the EKG
course, the laceration course, the abscess

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course, the interactive clinical pathways.

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00:00:49,121 --> 00:00:52,301
So many things to help
you in your practice.

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Go spend some money, get a gift
card, become a subscriber, and

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00:00:56,891 --> 00:00:59,561
have a wonderful Thanksgiving.

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00:00:59,761 --> 00:01:02,461
And now let's jump into
this month's episode.

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Sam: All ladies and gentlemen, welcome
back to another episode of Emplify.

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00:01:07,851 --> 00:01:13,101
I am one of your hosts, Sam Ashoo,
and on the other end of the microphone

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T.R. Eckler: Dr. TR Eckler,
just like barbiturates.

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I am back baby.

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Sam: here to talk about barbiturates
only and why you should be using them,

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T.R. Eckler: Also gabapentin, that's
really gonna be a theme for me today.

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Sam: Okay.

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All right.

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There you have it.

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There's the summary.

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Thanks for joining us
everybody, and until next.

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Oh wait, we're not done yet.

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T.R. Eckler: High yield quick hits.

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Sam: That's right.

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That's super quick.

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What are we talking about today?

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We're talking about the emergency
medicine practice article from November,

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2025, authored by Dr. Koo on the
diagnosis and management of ED patients

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with alcohol withdrawal syndrome.

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A very timely article given
the holidays coming up.

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Many people seem to seek solace in alcohol
inappropriately or maybe appropriately.

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I don't know.

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I don't know your families, but it's
definitely something we're going to see.

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We see it here frequently in
Tallahassee, around weekends, Friday

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nights, Saturday nights, football
weekends, homecoming college students.

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And so this is a, a very timely topic and
quite relevant to the emergency department

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and once again, an outstanding article.

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Some interesting introductory statistics.

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I thought it was interesting to see that
the data on alcohol intoxication and ED

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visits shows that there's actually been
an increase steadily over the last decade

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for ED visits related to alcohol use.

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And mortality from alcohol withdrawal
ranges anywhere from one to 5%.

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That's mortality.

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So that's death we're talking about there.

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And among heavy alcohol users admitted to
the hospital, that climbs a little higher,

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just a kind of peeking around 7% or so.

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So it's not a simple problem to fix.

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And the spectrum of patients
here runs the gamut.

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You got the people who are gonna
go home and you got the people

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who are gonna go to observation.

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You got the people who have to be
admitted to inpatient, and then

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you got the critically sick who
are going to the ICU and we're

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gonna talk about all of them today.

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T.R. Eckler: this is not just kind
of your alcoholic that shows up

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disheveled on the EMS stretcher.

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Like, you know, I've seen so many
different iterations of alcoholic

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patients come in that I've just
learned to develop a really high

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suspicion for this kind of thing.

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I knew someone in medical school whose
father went in for like a normal surgery

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and went into alcohol withdrawal and
died 'cause nobody really kind of

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knew that he was drinking that much.

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I've seen so many complications from
the patient that seemed intoxicated

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or delirious that actually also had a
head bleed or also had, co ingestion

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or they had also overdosed on Tylenol.

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And there's just so much complexity
in pathology and this is just such

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bread and butter, you know, really
challenging emergency medicine, that

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it's a great thing to really think hard
about every time you have one of these

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patients as to how much you wanna work
'em up and whether they're getting

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better, whether you need to do more.

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Sam: Yeah.

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Yeah, that's well said.

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And even, you know, these patients,
much like the patients we talked about

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previously with adrenal insufficiency,
these patients can present with alcohol

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withdrawal as their primary diagnosis.

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It can be a secondary diagnosis, it can
be because of some other thing going

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on, and they can't drink alcohol, which
is what's thrown them into withdrawal.

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And it can mimic sepsis
and drug intoxication.

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So this becomes a very pertinent
diagnosis and one that you have to

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have a high suspicion for, for sure.

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And I thought the author did a great
job of of course finding an evidence

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base for all the recommendations, but
also saying, Hey, you know, there is

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kind of a, a paucity of good evidence
because it's hard to get informed

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consent for this population in general.

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And there's a lack of a homogenous
population, meaning that there's

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such a variety, like I mentioned
before, from the people going home

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to the people going to the ICU.

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It's difficult to find something
that works in general for that

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entire spectrum, and we end up
talking about things that work for

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specific segments of this population.

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If you're not aware, under typical
conditions, about 90% of your ingested

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alcohol is absorbed within an hour.

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It's a nice little tidbit there.

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And another one is that absorption
occurs starting in the gastrum or in the

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stomach, and your gastric mucosa have
alcohol dehydrogenase in them, which is

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actually higher in males than in females.

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Which therefore leads to a
higher bioavailability of

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alcohol in females and males.

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That's one of the reasons.

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But also in your patients who've had
gastric bypass surgery will have less

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alcohol dehydrogenase secretion in
the stomach to metabolize alcohol.

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So there are small amounts of alcohol
that are excreted in the kidneys

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and in the lungs and in the sweat.

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But most of it is going to be metabolized
by the liver and eventually turned

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into acetaldehyde and hopefully
then goes through that wonderful

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kreb cycle that we all remember.

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But  the acetaldehyde, if it builds up
enough, is what gives you that kind of

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the hangover cluster of symptoms and the
severity of that is directly dependent to

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the amount of alcohol that you consumed,
because you can overwhelm that enzyme that

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breaks down the alcohol and lead to a lot
of this stuff building up in your system.

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And so if you have someone who is
alcohol intoxicated, your typical

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metabolism is going to be about 20
milligrams per deciliter per hour.

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And if they're an experienced alcoholic,
they can upregulate those enzymes and

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metabolize, you know, anywhere from 25
to 35 milligrams per deciliter per hour.

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But it isn't gonna go any
much faster than that.

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So even in your chronic alcoholic who's
got a sky high alcoholic level, you're

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gonna be watching those people if they're
heavily intoxicated for a long, long time.

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Which brings me to my first
question in trivia with TR.

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Oh yeah, you forgot we
do that now, don't we?

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Here we go.

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This is uh, easy, easy, multiple choice.

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Which of the following is a primary
mechanism by which chronic alcohol use

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alters neuro transmission in the brain?

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All right, here we go.

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Activation of the NMDA
receptor by alcohol.

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Decreased GABAergic activity during
alcohol consumption, downregulation

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of GABA receptors and upregulation
of the NMDA receptors, inhibition

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of the CYP two E one enzyme or
stimulation of serotonin release.

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So which of these is the primary
mechanism by which chronic alcohol use

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alters neuro transmission in the brain?

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T.R. Eckler: Gonna go with choice C.

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Sam: It is C, sir. Well done.

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Downregulation of GABA A receptors
and upregulation of NMDA receptors

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is actually the physiologic mechanism
by which alcohol has its use.

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And chronic use leads to an increase
in both of those things, which means

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you have a downregulation of your
suppressive activity and an upregulation

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of your NMDA excitatory receptors
which is all great if you've got

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alcohol in your system all the time.

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But then when that alcohol's
gone,  we have some problems.

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And those problems lead to
the presentation in the ER.

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and there is a great table as always, on
page five, discussing the differential

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diagnosis of alcohol withdrawal, which
by the way is pretty broad, and that

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is primarily due to the fact that
alcohol withdrawal symptom presents

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with tachycardia, with hypertension
with tremors and with multiple system

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involvement and multiple vital sign
abnormalities, which you can get from

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multiple other things like drug ingestions
from sympathomimetics, antimuscarinics,

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sedative hypnotic withdrawal, severe
alcohol intoxication, interestingly,

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will look like severe alcohol withdrawal.

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And so sometimes it can
be difficult to tell.

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And serotonin syndrome, all
of those toxicologic diseases

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should be in the differential.

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And then you've got some other
medical things like thyrotoxicosis,

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encephalitis, acute psychosis.

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So if they're having active
delirium and visual hallucinations,

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it can be hard, especially if
there's a psychiatric history.

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Hypoglycemia, head trauma,
and sepsis and septic shock.

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So lots of disease processes,
especially pretty serious ones

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that can mimic that presentation.

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And things to keep in mind when
you're suspecting someone has

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alcohol withdrawal symptom.

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And when we talk about our pre-hospital
colleagues and what they can do

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there was a pretty good section here.

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I really enjoyed reading the description
of all of the things that our

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pre-hospital colleagues are already doing.

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So one of the biggest thing is rapid
transport to an appropriate facility.

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And when discussing that, the author
was quick to point out that about 40%

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of all ED visits for alcohol related
complaints arrive by ambulance.

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So, you know, a bulk of the population
is coming by EMS and that the

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presence of markedly abnormal vital
signs or severe agitation prompts

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pre-hospital personnel to transport
the patient to a medical facility

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rather than a psychiatric facility.

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Because in many areas we have
sobering centers or places where

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EMS can take somebody to sober up if
they're thought to just be alcohol

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intoxicated which are wonderful.

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There's good evidence behind those
facilities that they are appropriate

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and that they can reduce ED utilization.

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In fact, the data suggests there
was a 2019 review and found only

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00:10:17,320 --> 00:10:20,800
4% of patients got transferred
from sobering centers to the ED.

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So that means 96% of the time
we're getting that decision right.

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So that's a very important
distinction that our pre-hospital

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colleagues have to make.

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And when they figure out, Hey, this
person needs to go to the medical

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00:10:32,750 --> 00:10:36,450
side, then there is some therapy
they can initiate on the way to the

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hospital, specifically benzodiazepines,
depending on what they're carrying.

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So IM midazolam, collecting information
about possible ingestion or co ingestions

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00:10:44,980 --> 00:10:48,730
or drug utilization from the patient
or from other people who are on the

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00:10:48,760 --> 00:10:52,520
scene trying to see if they see obvious
evidence for drug paraphernalia there.

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All of these things become very, very
important and then measuring that mental

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00:10:57,855 --> 00:11:00,165
status and how it changes over time.

197
00:11:00,165 --> 00:11:03,512
So depending on how long the transport
is, they can get a little bit of time with

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00:11:03,512 --> 00:11:06,152
the patient and trend their mental status.

199
00:11:06,152 --> 00:11:09,542
And so by the time they get to the ED, if
they're floridly confused but didn't start

200
00:11:09,542 --> 00:11:11,312
that way, that can be an important clue.

201
00:11:11,682 --> 00:11:16,362
So lots of things that our EMS
personnel can do to help us in not

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00:11:16,362 --> 00:11:20,772
only gathering information, but helping
decipher exactly where they should go.

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00:11:20,962 --> 00:11:22,762
Whether that's a sobering center or an ED,

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00:11:23,387 --> 00:11:25,297
T.R. Eckler: Have you ever worked
somewhere that had a sobering center?

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00:11:25,997 --> 00:11:28,757
Sam: I kind of thought that one of
the pods in our emergency department

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00:11:28,757 --> 00:11:29,957
was the sobering center for a while.

207
00:11:30,664 --> 00:11:33,904
T.R. Eckler: I think having just
worked Halloween where we did reopen

208
00:11:33,904 --> 00:11:36,904
one of the pods to become a sobering
center, I would tell you that

209
00:11:36,904 --> 00:11:38,524
that's not an inaccurate assessment.

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00:11:38,524 --> 00:11:42,274
But when I was in Denver Health doing my
away rotation in medical school, they had

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00:11:42,274 --> 00:11:45,694
one of these for Denver Health, and it
was such a refreshing thing to be like,

212
00:11:45,844 --> 00:11:49,834
wait, you can just send the intoxicated
patients that look pretty good somewhere.

213
00:11:49,834 --> 00:11:51,394
And they were like, yeah, you
can just send them all out.

214
00:11:51,394 --> 00:11:54,094
Like they just go over to the sobering
center and then a couple will come

215
00:11:54,094 --> 00:11:55,144
back, but most of 'em are fine.

216
00:11:55,444 --> 00:11:58,654
And it was just such a great way to
decompress your ER, especially at

217
00:11:58,654 --> 00:12:00,514
like those peak evening kind of times.

218
00:12:00,738 --> 00:12:03,438
It was a well thought out and
highly effective intervention

219
00:12:03,438 --> 00:12:04,308
from what I remember.

220
00:12:04,848 --> 00:12:07,638
Sam: Now, in that area, they went
to the Sobering center from the ED.

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00:12:07,698 --> 00:12:09,918
So they came to the ED first, and
then you decided if they could go.

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00:12:10,083 --> 00:12:11,293
T.R. Eckler: And, or they
could go straight there.

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00:12:11,293 --> 00:12:13,803
It kind of depended on who brought 'em
in and things like that, but it was an

224
00:12:13,803 --> 00:12:16,023
option from the ER to move them to there.

225
00:12:16,023 --> 00:12:19,560
And I, I thought it was just one
of those neat ways to kind of

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00:12:19,560 --> 00:12:20,730
help you move through the volume.

227
00:12:20,730 --> 00:12:22,110
So it was a positive experience.

228
00:12:22,110 --> 00:12:24,570
And then I just wanted to
highlight how much I appreciate.

229
00:12:24,790 --> 00:12:28,180
I think IM midazolam is just such
a great choice for these patients

230
00:12:28,180 --> 00:12:29,140
in the prehospital setting.

231
00:12:29,410 --> 00:12:33,010
'cause I think that giving longer
acting benzos sometimes to these

232
00:12:33,010 --> 00:12:36,140
patients will kind of cloud the
picture for a longer period of time.

233
00:12:36,380 --> 00:12:39,590
Whereas I really like when I get a
short term control from EMS and then

234
00:12:39,590 --> 00:12:42,200
they come in and I can kind of get a
sense in the first hour or two as to

235
00:12:42,200 --> 00:12:46,070
where they're going as opposed to like,
that starts to sneak by me and then

236
00:12:46,070 --> 00:12:48,290
it's a couple hours later and maybe
they're getting admitted for something

237
00:12:48,290 --> 00:12:49,610
and then stuff starts to wear off.

238
00:12:49,610 --> 00:12:51,950
So I always really like when
pre-hospital people can give more

239
00:12:51,950 --> 00:12:53,300
short acting things if they can.

240
00:12:53,825 --> 00:12:54,995
Sam: Yes, yes, absolutely.

241
00:12:55,115 --> 00:12:57,425
And I'm sure the pre-hospital
people like it as well.

242
00:12:57,845 --> 00:13:02,025
IM Midazolam is a great drug, works
super fast intramuscularly and as you

243
00:13:02,025 --> 00:13:04,515
said, is short acting, kind of the
ideal agent for pre-hospital setting.

244
00:13:05,215 --> 00:13:08,845
And then when they get to the ED
and it's time to obtain our history,

245
00:13:08,845 --> 00:13:10,795
assuming we can get it from the patient.

246
00:13:10,825 --> 00:13:14,755
Table two on page six is a great
summary of the kinds of things that we

247
00:13:14,755 --> 00:13:18,835
want to know when we're interviewing
somebody to decide if they have risk

248
00:13:18,835 --> 00:13:20,335
factors for alcohol withdrawal syndrome.

249
00:13:20,395 --> 00:13:25,117
Like  have they personally had
alcohol withdrawal syndrome before?

250
00:13:25,267 --> 00:13:27,907
That's probably the most
important question to ask.

251
00:13:28,147 --> 00:13:29,827
But also, is there a family history of it?

252
00:13:30,097 --> 00:13:35,087
Do they have any known metabolic
derangements, liver problems, cirrhosis?

253
00:13:35,277 --> 00:13:37,527
Do they have a history of
thrombocytopenia that kind of

254
00:13:37,527 --> 00:13:38,937
goes hand in hand with cirrhosis?

255
00:13:39,267 --> 00:13:42,417
Also important to ask when
their last drink was, how

256
00:13:42,417 --> 00:13:43,707
much did they normally drink?

257
00:13:43,767 --> 00:13:46,887
Have they ever had withdrawals in
the past, and how severe were they?

258
00:13:46,887 --> 00:13:48,807
Did they result in an ICU admission?

259
00:13:48,807 --> 00:13:51,157
Did they have true delirium tremens?

260
00:13:51,177 --> 00:13:53,847
Did they have visual and
auditory hallucinations?

261
00:13:53,967 --> 00:13:55,737
Have they ever had withdrawal seizures?

262
00:13:55,917 --> 00:13:59,337
All those are very, very
pertinent questions to ask.

263
00:13:59,697 --> 00:14:04,041
And if for some reason you're able to
elicit that they have stopped drinking

264
00:14:04,064 --> 00:14:07,218
or cut back on their drinking, you
really have to follow it up with a

265
00:14:07,218 --> 00:14:09,378
question about why that's the case.

266
00:14:09,468 --> 00:14:13,788
If they want to stop drinking, that's
fantastic, but if you forgot to ask

267
00:14:13,788 --> 00:14:17,478
why, and it turns out they have severe
epigastric abdominal pain and acute

268
00:14:17,478 --> 00:14:20,808
pancreatitis, and that's why they
stopped drinking, that's an important

269
00:14:20,808 --> 00:14:22,758
piece of information to elicit as well.

270
00:14:23,313 --> 00:14:25,623
T.R. Eckler: This is such a
patient population that I just

271
00:14:25,623 --> 00:14:27,183
have more questions always

272
00:14:27,385 --> 00:14:30,751
When I try to teach students about
this, I'm like, you know, 1% of the

273
00:14:30,751 --> 00:14:34,261
time they've just decided it's time and
they've decided to stop drinking the

274
00:14:34,261 --> 00:14:38,101
other 99% of the time, there's some other
reason and you really wanna know that.

275
00:14:38,131 --> 00:14:40,951
'cause it might be pancreatitis,
it might be a GI bleed.

276
00:14:41,071 --> 00:14:45,001
It might be because they started really
going into DTs and they realized that

277
00:14:45,001 --> 00:14:48,271
things were getting worse or they
got into something else like a toxic

278
00:14:48,271 --> 00:14:52,771
alcohol or they overdosed or something
else has happened that has interrupted

279
00:14:52,771 --> 00:14:54,246
their normal pattern of behavior.

280
00:14:54,481 --> 00:14:57,791
And you need to have just the highest
level of suspicion 'cause these are

281
00:14:57,791 --> 00:15:04,071
people that are not doing something that
is respected and they're going to always

282
00:15:04,071 --> 00:15:05,781
be trying to hide it and minimize it.

283
00:15:05,931 --> 00:15:10,011
So the more that you can develop that
rapport with them and try to really like

284
00:15:10,011 --> 00:15:13,491
establish the trust and try to establish
as much that you're there to help them.

285
00:15:13,551 --> 00:15:16,251
And then gradually build to
where you ask about their use

286
00:15:16,251 --> 00:15:17,601
and you ask about their history.

287
00:15:17,811 --> 00:15:21,321
And I think something that I learned
too is how much more common the tactile

288
00:15:21,441 --> 00:15:23,301
hallucinations are than the visual ones.

289
00:15:23,481 --> 00:15:26,631
I'm not asking enough about if you
feel something like that, because

290
00:15:26,631 --> 00:15:29,511
I feel like everyone's got worms
and bugs in the ER these days.

291
00:15:29,721 --> 00:15:32,301
But I think this is something where
I'm gonna try to tease that more

292
00:15:32,301 --> 00:15:35,781
delicately from these patients to
see if I can catch earlier which ones

293
00:15:35,781 --> 00:15:39,325
are actually heading for DTs and need
to be looking at like an ICU stay.

294
00:15:40,025 --> 00:15:43,085
Sam: And, you know, I always found that
my patients fell into two categories.

295
00:15:43,085 --> 00:15:47,255
Those who were completely in denial or
were still trying to hide it from people.

296
00:15:47,255 --> 00:15:50,225
And so they were minimizing how much
they drink and those who were just

297
00:15:50,225 --> 00:15:52,685
completely open about everything, I
could just say, how much do you drink?

298
00:15:52,685 --> 00:15:53,765
They would be completely upfront.

299
00:15:53,765 --> 00:15:55,295
And I'd say, have you ever
had procedures before?

300
00:15:55,295 --> 00:15:58,205
Oh yeah, I've had three and
I've been at ICU once and I've

301
00:15:58,205 --> 00:15:59,435
been to detox a hundred times.

302
00:15:59,435 --> 00:16:02,555
And then I would always follow it up with,
you know, do you want to go back today?

303
00:16:02,585 --> 00:16:03,515
Is today the day?

304
00:16:03,705 --> 00:16:06,375
And sometimes people would just
say, no, no, I'm gonna go right

305
00:16:06,375 --> 00:16:07,365
back and start drinking again.

306
00:16:07,365 --> 00:16:09,645
I go, okay, so we're
not seeking detox today.

307
00:16:09,645 --> 00:16:10,755
Like, nope, no, not at all.

308
00:16:10,965 --> 00:16:13,905
And sometimes people would say yes, you
know, I've been there a hundred times.

309
00:16:13,905 --> 00:16:15,285
Today's gonna be 101.

310
00:16:15,285 --> 00:16:17,105
I'm hoping it's gonna
be the time that sticks.

311
00:16:17,415 --> 00:16:19,140
And that's important to differentiate.

312
00:16:19,140 --> 00:16:22,450
So don't be afraid to just be
blunt and ask those questions.

313
00:16:22,450 --> 00:16:23,680
It doesn't have to be accusatory.

314
00:16:23,680 --> 00:16:24,580
Just 'cause you're asking.

315
00:16:24,930 --> 00:16:26,830
T.R. Eckler: I also think that
this is also more of a history

316
00:16:26,830 --> 00:16:28,240
piece than more of an exam piece.

317
00:16:28,240 --> 00:16:31,390
So I wanna move this forward in the
discussion, but I think it's important

318
00:16:31,390 --> 00:16:35,100
to ask about other medications
they're using, because I find that

319
00:16:35,530 --> 00:16:38,590
in other populations I'm more worried
about, are you taking propanolol?

320
00:16:38,590 --> 00:16:40,480
Are you taking labetalol or metoprolol?

321
00:16:40,480 --> 00:16:43,600
Are you taking something that's gonna,
you know, like slow down your heart rate?

322
00:16:43,840 --> 00:16:47,200
And these are patients that are, because
their alcohol abuse are gonna be more

323
00:16:47,200 --> 00:16:50,500
prone to AFib, they're gonna be more
prone to having other medical problems.

324
00:16:50,680 --> 00:16:54,310
And if they're taking a beta blocker
or if they're taking clonidine or

325
00:16:54,310 --> 00:16:59,623
tizanidine or guanfacine that's gonna
blunt their withdrawal symptoms and the

326
00:16:59,623 --> 00:17:02,680
appearance of their withdrawal and kind
of dampen the things that are gonna make

327
00:17:02,680 --> 00:17:03,790
you think that they're getting worse.

328
00:17:03,940 --> 00:17:07,030
So that was something that I took away
from this, that I needed to be more

329
00:17:07,030 --> 00:17:11,020
cautious of, to make sure that this wasn't
someone that I was hiding their symptoms

330
00:17:11,020 --> 00:17:12,820
by having other medicines in their tank.

331
00:17:13,209 --> 00:17:14,469
Sam: yeah, yeah, exactly.

332
00:17:14,474 --> 00:17:17,992
We're not, covering up alcohol withdrawal
because we forgot to ask about medications

333
00:17:17,992 --> 00:17:19,892
that might blunt some of those symptoms.

334
00:17:20,592 --> 00:17:20,892
Alright.

335
00:17:20,892 --> 00:17:21,762
Couple more questions.

336
00:17:21,762 --> 00:17:25,092
Which of the following statements
about Sobering Centers is accurate?

337
00:17:25,722 --> 00:17:28,632
So they provide long-term detox programs.

338
00:17:29,262 --> 00:17:32,232
They are appropriate for
patients with severe withdrawal.

339
00:17:32,932 --> 00:17:36,472
They manage medical complications
of alcohol withdrawal.

340
00:17:37,172 --> 00:17:40,892
They typically monitor vital
signs and offer referrals.

341
00:17:41,592 --> 00:17:44,142
And they require inpatient
admission orders?

342
00:17:44,722 --> 00:17:46,770
T.R. Eckler: It's D. I love them for that.

343
00:17:47,309 --> 00:17:47,699
Sam: That's right.

344
00:17:47,939 --> 00:17:48,299
That's right.

345
00:17:48,299 --> 00:17:49,079
They do a great job.

346
00:17:49,079 --> 00:17:50,189
They're monitoring vital signs.

347
00:17:50,189 --> 00:17:52,859
So yes, they're doing that and they're
offering referrals and they're there

348
00:17:53,099 --> 00:17:56,489
literally just to keep someone until
they're sober enough to go home.

349
00:17:56,544 --> 00:17:59,634
They're not there to treat alcohol
withdrawal, but they do provide

350
00:17:59,634 --> 00:18:02,484
a good service and they do offer
referrals to patients for sure.

351
00:18:03,184 --> 00:18:04,414
All right, one more question.

352
00:18:04,414 --> 00:18:07,774
What is the most predictive
risk factor for developing

353
00:18:07,774 --> 00:18:09,124
alcohol withdrawal syndrome?

354
00:18:09,124 --> 00:18:12,964
So when they're there in the ED and we're
trying to figure out, okay, what's your

355
00:18:12,964 --> 00:18:14,494
risk for alcohol withdrawal syndrome?

356
00:18:14,494 --> 00:18:16,144
What's the most predictive risk factor?

357
00:18:16,874 --> 00:18:21,024
A blood alcohol level on arrival
greater than one 50 B, a history

358
00:18:21,024 --> 00:18:27,004
of alcohol withdrawal seizures,
C, low serum potassium, D male

359
00:18:27,064 --> 00:18:30,004
sex, or E use of antidepressants.

360
00:18:30,704 --> 00:18:33,569
T.R. Eckler: My experience on
Halloween suggests that male sex

361
00:18:33,909 --> 00:18:36,044
is concerningly close to the truth.

362
00:18:36,254 --> 00:18:39,164
But I think that this is, if
you've previously had alcohol

363
00:18:39,164 --> 00:18:42,104
withdrawal and seizures, that
is the most predictive factor.

364
00:18:42,344 --> 00:18:42,494
I

365
00:18:42,589 --> 00:18:42,879
Sam: Yeah.

366
00:18:43,044 --> 00:18:45,474
T.R. Eckler: Found that the discussion
in the article about kindling that

367
00:18:45,474 --> 00:18:48,874
basically the more you feed the fire,
the harder it is to get it under

368
00:18:48,874 --> 00:18:51,374
control was very apt for these patients.

369
00:18:51,494 --> 00:18:55,364
And I, I really did think it characterized
some of these people that they're really

370
00:18:55,364 --> 00:18:58,214
kind of burning through themselves
and drinking harder and harder.

371
00:18:58,214 --> 00:19:00,434
And you need to be aware that
they're gonna need more and

372
00:19:00,434 --> 00:19:01,754
more benzos to control 'em.

373
00:19:01,754 --> 00:19:04,304
So you need to be ready to
escalate and get more aggressive.

374
00:19:04,304 --> 00:19:07,132
'cause they come in months later
and they may be significantly

375
00:19:07,132 --> 00:19:08,392
more ill than they were before.

376
00:19:09,092 --> 00:19:09,242
Sam: Yeah.

377
00:19:09,422 --> 00:19:09,572
Yeah.

378
00:19:09,572 --> 00:19:13,112
You brought up a great point there to this
point about kindling, meaning that the

379
00:19:13,112 --> 00:19:17,932
more times that someone cycles through
a severe alcohol withdrawal and then

380
00:19:17,992 --> 00:19:21,112
medical treatment and then goes back to
drinking and then comes back again in

381
00:19:21,112 --> 00:19:27,022
alcohol withdrawal, this cycle actually
makes it more difficult in subsequent

382
00:19:27,172 --> 00:19:30,502
episodes to treat their acute alcohol
withdrawal and they end up needing

383
00:19:30,532 --> 00:19:32,692
escalating doses of benzodiazepines.

384
00:19:32,692 --> 00:19:37,462
So if you have an EMR that allows you to
look back at prior admissions and see what

385
00:19:37,462 --> 00:19:42,142
they used last time, that's not enough to
judge what they're gonna need this time.

386
00:19:42,142 --> 00:19:45,522
Just know that it's a very good
possibility they'll need more this

387
00:19:45,522 --> 00:19:48,792
admission than they did during the
previous admission, especially if there

388
00:19:48,792 --> 00:19:50,802
have been multiple prior admissions.

389
00:19:50,802 --> 00:19:53,532
So that was a great point in the article.

390
00:19:54,232 --> 00:19:57,192
And also 'cause I like figures and tables.

391
00:19:57,192 --> 00:20:02,322
Figure one in the article on page six for
alcohol withdrawal syndrome, the timeline,

392
00:20:02,352 --> 00:20:03,882
which I thought was very helpful.

393
00:20:04,072 --> 00:20:07,372
You've got the green timeline, which
is six to 12 hours where they're just

394
00:20:07,372 --> 00:20:10,672
symptomatic headache, anxiety, maybe
some nausea and vomiting and some

395
00:20:10,672 --> 00:20:13,042
abdominal pain, palpitations and tremors.

396
00:20:13,312 --> 00:20:18,622
And then once you get past 12
hours, that 12 to 36 hour range has

397
00:20:18,622 --> 00:20:22,762
worsening tachycardia, increasing
blood pressure, maybe seizures,

398
00:20:22,942 --> 00:20:25,522
maybe agitation, maybe fever.

399
00:20:25,672 --> 00:20:30,952
And then finally the worst case in
the red zone, 36 hours to a week where

400
00:20:30,952 --> 00:20:34,222
they get the true disorientation,
the altered mental status, the

401
00:20:34,222 --> 00:20:36,212
hallucinations and the delirium tremons.

402
00:20:36,232 --> 00:20:39,442
So kind of three buckets to put
your patient in depending on

403
00:20:39,532 --> 00:20:41,062
when their last drink occurred.

404
00:20:41,332 --> 00:20:46,012
and kind of helps gauge who you think is
going to be able to go where, depending

405
00:20:46,012 --> 00:20:47,662
on how far on the spectrum they are.

406
00:20:48,312 --> 00:20:51,312
T.R. Eckler: don't put too much faith
into the answer as to when exactly their

407
00:20:51,312 --> 00:20:55,962
last drink was, because much like the last
time you used opiates, I'm not sure that

408
00:20:56,082 --> 00:21:00,012
they're regularly going to defer to giving
you the honest truth in these cases.

409
00:21:00,152 --> 00:21:00,572
Sam: Yeah.

410
00:21:01,082 --> 00:21:03,602
Not to mention the fact that, you
know, in order to tell you when their

411
00:21:03,602 --> 00:21:06,962
last drink was, you have to know what
time it is now and what day it is.

412
00:21:07,309 --> 00:21:08,729
T.R. Eckler: Or what time it was then

413
00:21:08,989 --> 00:21:09,559
Sam: Exactly.

414
00:21:10,634 --> 00:21:10,919
T.R. Eckler: Because you
might have passed out

415
00:21:10,939 --> 00:21:11,869
Sam: Exactly.

416
00:21:13,184 --> 00:21:14,184
T.R. Eckler: It's not something
that I put a lot of faith in.

417
00:21:14,204 --> 00:21:16,572
I'd say, okay, alright, we'll
kind of see how it goes.

418
00:21:17,246 --> 00:21:18,536
Sam: Fair enough, fair enough.

419
00:21:19,146 --> 00:21:21,786
When it comes to physical
examination, there are some things

420
00:21:21,786 --> 00:21:22,536
you're gonna be looking for.

421
00:21:22,536 --> 00:21:28,171
Tremor, nausea, vomiting, hallucinations,
psychomotor agitation, anxiety,

422
00:21:28,171 --> 00:21:30,691
seizures, and autonomic hyperactivity.

423
00:21:30,691 --> 00:21:34,801
Those are all the DSM five TR criteria.

424
00:21:34,861 --> 00:21:37,171
And that's not TR as in
TR Eckler, by the way.

425
00:21:37,321 --> 00:21:38,941
That's TR as in text revision.

426
00:21:38,941 --> 00:21:39,121
So.

427
00:21:39,287 --> 00:21:41,147
T.R. Eckler: Do you feel like I've
seen enough of these patients to

428
00:21:41,147 --> 00:21:42,487
have a scoring scale of my own?

429
00:21:42,556 --> 00:21:43,786
Sam: You might, you might.

430
00:21:44,267 --> 00:21:48,397
T.R. Eckler: I was alarmed though
that the DSM five said that you only

431
00:21:48,397 --> 00:21:51,937
need two of the eight to qualify
because that seemed just about as

432
00:21:51,937 --> 00:21:53,767
broad as usually is with these people.

433
00:21:53,937 --> 00:21:56,637
All alcoholics can kind of fit
into the withdrawal picture

434
00:21:56,637 --> 00:21:57,307
if they try hard enough.

435
00:21:57,836 --> 00:21:59,006
Sam: Yes, yes, yes.

436
00:21:59,006 --> 00:22:01,346
That makes it very, very
likely that they're gonna fall

437
00:22:01,346 --> 00:22:02,696
into that bucket for sure.

438
00:22:02,976 --> 00:22:04,536
Now that doesn't tell you
where they are on the spectrum.

439
00:22:04,536 --> 00:22:08,270
That just tells you that they have
enough  elements to get the diagnosis,

440
00:22:08,270 --> 00:22:12,010
alcohol withdrawal syndrome, and
then there is a good discussion

441
00:22:12,010 --> 00:22:14,650
there about scoring the severity.

442
00:22:14,650 --> 00:22:16,010
So this is interesting.

443
00:22:16,010 --> 00:22:18,920
I actually had a recent debate
with some emergency physicians

444
00:22:18,920 --> 00:22:20,570
about this particular issue.

445
00:22:20,730 --> 00:22:24,390
When we talk about the CIWA-AR, so this
is the Clinical Institute Withdrawal

446
00:22:24,390 --> 00:22:28,500
Assessment of Alcohol Scale revised.

447
00:22:28,500 --> 00:22:32,700
So that's the CIWA-AR,
or Alcohol Scale Revised.

448
00:22:33,060 --> 00:22:34,530
And it's a questionnaire.

449
00:22:34,690 --> 00:22:37,750
It's got several questions on here,
just asking about everything from

450
00:22:37,750 --> 00:22:41,410
nausea and vomiting and tremors and
sweats to anxiety and agitation.

451
00:22:41,620 --> 00:22:44,920
And then the disturbances,
tactile disturbances, auditory

452
00:22:44,920 --> 00:22:49,250
disturbances, visual disturbances
headache, and then orientation.

453
00:22:49,280 --> 00:22:52,550
And some of these are objective, some
of these are very subjective 'cause

454
00:22:52,550 --> 00:22:55,700
you're asking them or you're just
kind of interpreting them yourself.

455
00:22:55,980 --> 00:22:59,040
And depending on where they score,
they can be mild, moderate, or severe.

456
00:22:59,040 --> 00:23:03,450
So less than 10 is mild, 10 to
18 is moderate, and more than

457
00:23:03,570 --> 00:23:06,300
19 or 19 or more is severe.

458
00:23:07,000 --> 00:23:10,600
And that becomes helpful
for a number of reasons.

459
00:23:10,600 --> 00:23:12,910
Now, the debate I had with the
emergency physicians we were

460
00:23:12,910 --> 00:23:15,850
talking to was, who does this?

461
00:23:15,880 --> 00:23:20,080
And whether or not this is required,
it's obviously not required to make the

462
00:23:20,080 --> 00:23:22,210
diagnosis of alcohol withdrawal syndrome.

463
00:23:22,210 --> 00:23:26,320
You don't have to have a specifically
high or low CIWA to make the diagnosis.

464
00:23:26,380 --> 00:23:33,040
But it is helpful for monitoring
the progression of their symptoms or

465
00:23:33,040 --> 00:23:36,850
hopefully the improvement of their
symptoms, their response to therapy.

466
00:23:37,120 --> 00:23:42,040
And for anybody you're gonna hand off the
patient to, so if you're gonna admit them

467
00:23:42,040 --> 00:23:46,580
to the inpatient wards or the OBS unit,
one of your colleagues, or the ICU, it's

468
00:23:46,580 --> 00:23:50,330
important for them to know where this
person started, where they are now, and if

469
00:23:50,330 --> 00:23:51,920
they're improving with what you've done.

470
00:23:52,170 --> 00:23:55,320
And there has to be some kind
of objective measure for that.

471
00:23:55,320 --> 00:23:57,810
And honestly, a lot of times our
nursing colleagues are the ones

472
00:23:57,810 --> 00:23:59,130
who get stuck having to do this.

473
00:23:59,400 --> 00:24:03,620
And this can be done, you know, once
every hour, once every four hours.

474
00:24:03,620 --> 00:24:07,010
It just depends on how sick the
person is and what your protocol is.

475
00:24:07,280 --> 00:24:10,220
But it's helpful to have
something documented.

476
00:24:10,620 --> 00:24:14,790
And also as is always the case, when
there is something documented, it

477
00:24:14,790 --> 00:24:18,090
ends up getting kind of eaten up by
our coding and billing colleagues.

478
00:24:18,090 --> 00:24:23,760
And so many insurance companies will
use an initial CIWA score to justify

479
00:24:24,030 --> 00:24:27,150
an OBS versus an inpatient payment.

480
00:24:27,240 --> 00:24:31,246
And so even though it may be something
your nursing colleague did and you

481
00:24:31,246 --> 00:24:34,936
documented something far worse, if
your nursing colleague documents a very

482
00:24:34,936 --> 00:24:40,396
minor CIWA score, this person may end
up just reimbursing at an OBS level.

483
00:24:40,646 --> 00:24:45,076
And so it does have some repercussions but
it is also clinically helpful, especially

484
00:24:45,076 --> 00:24:47,326
if you're gonna trend ongoing therapy.

485
00:24:47,676 --> 00:24:50,316
T.R. Eckler: I think, not to jump the
gun, but I think that there's value

486
00:24:50,316 --> 00:24:56,626
here when you're looking more at
giving longer acting, you know, less

487
00:24:56,806 --> 00:25:00,826
exhilarating benzos, or when you look
at a drug like phenobarbital, because

488
00:25:00,826 --> 00:25:03,376
I think that patients are gonna be
more likely to give you an honest

489
00:25:03,376 --> 00:25:06,736
assessment if they know there's not a
mountain of Valium coming their way.

490
00:25:07,036 --> 00:25:11,046
So I think that there's more value
here if you can get kind of a gradual

491
00:25:11,046 --> 00:25:14,186
control of the patient's symptoms with
something that's longer acting and less

492
00:25:14,186 --> 00:25:16,046
of a euphoric high kind of creating.

493
00:25:16,326 --> 00:25:18,736
Did you look at any of the other
scoring systems they have out

494
00:25:18,736 --> 00:25:20,086
there now like they suggested here.

495
00:25:20,751 --> 00:25:23,521
Sam (2): Yeah, there is two others
that the author mentioned, The BAWS

496
00:25:23,541 --> 00:25:27,831
or the Brief Alcohol Withdrawal
Scale and the PAWSS or prediction of

497
00:25:27,831 --> 00:25:31,115
Alcohol Withdrawal Severity Scale,
all three of which are on MD Calc.

498
00:25:31,356 --> 00:25:35,106
T.R. Eckler: I thought BAWS and CIWA both
had the potential for, if you were the

499
00:25:35,106 --> 00:25:38,466
patient and you wanted to really enhance
your symptoms, everything could be a 10

500
00:25:38,466 --> 00:25:40,176
outta 10 or a seven outta seven I guess.

501
00:25:40,176 --> 00:25:41,436
'cause most of them are scored outta that.

502
00:25:41,766 --> 00:25:45,756
But I really liked the PAWSS 'cause
I think that it's a good way of

503
00:25:45,756 --> 00:25:49,326
saying, Hmm, you know, this is the
alcoholic patient I got, what's

504
00:25:49,326 --> 00:25:50,886
my level of concern about them?

505
00:25:50,886 --> 00:25:53,406
Do I think they need ICU
or step down or the floor?

506
00:25:53,586 --> 00:25:57,426
I thought this was a cool tool that I
think is gonna help me land patients more

507
00:25:57,426 --> 00:25:59,526
appropriately in the right level of care.

508
00:25:59,526 --> 00:26:02,496
'cause I think it's gonna tease out
some of the higher risk patients

509
00:26:02,496 --> 00:26:05,106
that I don't think I'm necessarily
asking all the right questions to.

510
00:26:05,806 --> 00:26:08,060
Sam: If you're concerned or
want to see what a CIWA looks

511
00:26:08,060 --> 00:26:09,320
like, it's there on page eight.

512
00:26:09,420 --> 00:26:12,000
There are a number of resources
online where you can just download

513
00:26:12,000 --> 00:26:15,210
this form and print it or put it in
a digital form and incorporate it in

514
00:26:15,210 --> 00:26:17,250
your EMR if it's not already there.

515
00:26:17,500 --> 00:26:21,400
It's probably the one that is the
most widely studied and has the

516
00:26:21,520 --> 00:26:24,410
biggest body of evidence behind
it, and that's the CIWA-AR.

517
00:26:24,650 --> 00:26:28,700
The others like you mentioned already
there are some in MD calc, the SEWS or the

518
00:26:28,700 --> 00:26:32,990
SEWS severity of ethanol withdrawal scale
is not on MD calc, but the other two are.

519
00:26:33,260 --> 00:26:35,450
There's not as much evidence
for those in the ED, but that

520
00:26:35,450 --> 00:26:36,650
doesn't mean they're not helpful.

521
00:26:36,650 --> 00:26:39,530
Just pick one, have something
that is consistently used.

522
00:26:39,720 --> 00:26:44,965
It is more helpful for everyone to
use the same one than it is for you

523
00:26:44,965 --> 00:26:47,605
to use one and for your inpatient
colleague to use a different one.

524
00:26:47,945 --> 00:26:51,585
So there may have to be some compromise
there, but the point is having some

525
00:26:51,585 --> 00:26:55,995
kind of objective or pseudo objective
measuring scale is helpful because it

526
00:26:55,995 --> 00:27:00,145
helps guide your therapy especially if
you're gonna be doing symptom management

527
00:27:00,205 --> 00:27:05,078
based dosing as opposed to just a
set schedule dosing for medications,

528
00:27:05,078 --> 00:27:06,098
which we'll get into in a second.

529
00:27:06,798 --> 00:27:09,933
T.R. Eckler: I would also just
add, I think that it's tricky to

530
00:27:09,933 --> 00:27:11,733
really assess hand fasciculations.

531
00:27:11,733 --> 00:27:14,763
I think that sometimes it's
convincing, but sometimes patients

532
00:27:14,763 --> 00:27:17,043
are trying to either enhance it
or they're trying to cover it up.

533
00:27:17,043 --> 00:27:18,573
They're trying to kind
of do one or the other.

534
00:27:18,753 --> 00:27:21,873
I find tongue fasciculations to
be a lot more reliable 'cause

535
00:27:21,873 --> 00:27:23,313
it's a pretty hard thing to do.

536
00:27:23,313 --> 00:27:25,053
And I'll often ask
patients to do it together.

537
00:27:25,233 --> 00:27:26,913
I'll be like, hold out your
hands and stick out your tongue.

538
00:27:27,123 --> 00:27:30,453
And they're used to it being hands, so
they won't think about their tongue.

539
00:27:30,573 --> 00:27:34,033
And I find that that gives me a kind
of cleaner indication of how ill

540
00:27:34,033 --> 00:27:36,613
they are and how I'm doing in terms
of controlling their withdrawal.

541
00:27:37,313 --> 00:27:38,288
Sam: Yeah, great points.

542
00:27:38,988 --> 00:27:42,858
There is an entity called Complicated
Alcohol Withdrawal, and that's really just

543
00:27:43,098 --> 00:27:48,168
as things are progressing and your alcohol
withdrawal now encompasses hallucinations

544
00:27:48,168 --> 00:27:53,248
or seizures and you're being diagnosed
with delirium or delirium tremons, those

545
00:27:53,603 --> 00:27:57,703
are encompassed by the global diagnosis
of complicated alcohol withdrawal.

546
00:27:58,003 --> 00:27:59,503
And then there is alcohol withdrawal.

547
00:27:59,633 --> 00:28:02,993
Hallucinosis which again is
kind of, we're just working

548
00:28:02,993 --> 00:28:04,413
our way up to delirium tremons.

549
00:28:04,433 --> 00:28:07,613
So this is hallucinations,
visual, auditory, or tactile.

550
00:28:07,743 --> 00:28:13,023
More frequently tactile, less frequently,
auditory and even less frequently visual.

551
00:28:13,263 --> 00:28:16,893
And this is anywhere from one to 12%
of patients, depending on how sick

552
00:28:16,893 --> 00:28:18,273
the population is, you're admitting.

553
00:28:18,583 --> 00:28:22,393
But they get this altered sensorium
and this eventually progresses to

554
00:28:22,393 --> 00:28:25,213
full-blown delirium tremons if untreated.

555
00:28:25,603 --> 00:28:27,913
And then there is alcohol withdrawal
seizures, which we've talked about

556
00:28:27,913 --> 00:28:31,093
on the podcast before when we
talked about status epilepticus.

557
00:28:31,143 --> 00:28:36,383
It's a pretty rare complication, less than
3% but it can occur and the treatment here

558
00:28:36,383 --> 00:28:41,593
is always benzodiazepines and not really
the standard anti-epileptic medications.

559
00:28:41,593 --> 00:28:44,293
They don't tend to do a good
job in this kind of scenario.

560
00:28:44,713 --> 00:28:50,263
Patients with alcohol use disorder are at
increased risk for lots of CNS conditions.

561
00:28:50,263 --> 00:28:55,273
So this is the rub, including
infections, subdural hematomas, metabolic

562
00:28:55,273 --> 00:28:57,553
derangement, and drug ingestion.

563
00:28:57,553 --> 00:29:01,453
And so even though they're coming in
seizing with a history of alcohol use,

564
00:29:01,723 --> 00:29:05,443
it can be difficult to say for sure
this is alcohol withdrawal until you've

565
00:29:05,443 --> 00:29:07,213
excluded all of those other things.

566
00:29:07,213 --> 00:29:08,293
Just keep that in mind.

567
00:29:08,884 --> 00:29:12,424
T.R. Eckler: I think the caution is when
you are having trouble controlling them.

568
00:29:12,424 --> 00:29:15,844
So you've given a couple rounds of
benzos and they're still having seizures.

569
00:29:16,054 --> 00:29:19,114
I've had patients like this
that now it's trauma, now it's a

570
00:29:19,114 --> 00:29:20,794
subarachnoid, now it's a poisoning.

571
00:29:20,794 --> 00:29:21,994
Now it's hypoglycemia.

572
00:29:21,994 --> 00:29:24,754
So you need to keep kind
of moving the gears.

573
00:29:24,754 --> 00:29:26,914
'cause EMS will come in and
say, ah, this is an alcoholic.

574
00:29:26,914 --> 00:29:27,334
We know him.

575
00:29:27,334 --> 00:29:28,174
He gets seizures.

576
00:29:28,324 --> 00:29:31,564
And you've gotta keep that high level
of suspicion that you know, they're

577
00:29:31,564 --> 00:29:34,144
sicker than they usually are, or
there's a problem I can't control.

578
00:29:34,144 --> 00:29:35,154
So it's gotta be something else.

579
00:29:35,154 --> 00:29:39,634
So I find that the CT scanner
and more labs and more workup

580
00:29:39,634 --> 00:29:40,594
is your best friend here.

581
00:29:40,594 --> 00:29:42,214
So keep following your gut.

582
00:29:42,914 --> 00:29:44,594
Sam: All right, and on that
note, another question.

583
00:29:44,654 --> 00:29:50,684
A 52-year-old man is brought to the
ED altered diaphoretic, grasping

584
00:29:50,744 --> 00:29:55,904
at the air he was last seen four
days ago for alcohol intoxication,

585
00:29:56,114 --> 00:29:58,184
what is the most likely diagnosis?

586
00:29:58,304 --> 00:30:00,134
Is it alcohol intoxication?

587
00:30:00,834 --> 00:30:03,374
Alcohol withdrawal, hallucinosis?

588
00:30:03,954 --> 00:30:05,844
Is it delirium tremons?

589
00:30:06,264 --> 00:30:09,594
Is it schizophrenia or is it
Wernicke's Encephalopathy?

590
00:30:10,294 --> 00:30:15,129
T.R. Eckler: I tell you that he could
be just hallucinosis or it could be

591
00:30:15,129 --> 00:30:16,369
heading towards delirium tremons.

592
00:30:16,389 --> 00:30:20,079
I would start with hallucinations, but
I would have a high index of suspicion

593
00:30:20,079 --> 00:30:21,399
that we were heading there too.

594
00:30:22,099 --> 00:30:23,129
Sam: Yeah, so you're correct.

595
00:30:23,129 --> 00:30:26,349
The answer, the technical answer is
delirium tremons, but delirium tremons

596
00:30:26,369 --> 00:30:28,559
your manifestation is gonna be delayed.

597
00:30:28,589 --> 00:30:31,589
So he was last seen four days
ago for alcohol intoxication.

598
00:30:31,589 --> 00:30:35,729
If he hasn't had a drink since then,
it takes about 72 hours to push

599
00:30:35,729 --> 00:30:39,169
you into that red zone where you're
in full blown delirium tremons.

600
00:30:39,369 --> 00:30:44,079
Your hallucinations are gonna start right
around 36 hours and so he is somewhere

601
00:30:44,079 --> 00:30:46,049
on the verge of delirium tremons.

602
00:30:46,339 --> 00:30:50,549
But yes, I will take alcohol withdrawal
hallucinosis because right at 36

603
00:30:50,549 --> 00:30:51,869
hours is when that's gonna begin.

604
00:30:52,109 --> 00:30:55,289
And either one of those could be
complicating this presentation.

605
00:30:55,989 --> 00:31:01,149
And on that note, let's talk about
diagnostic studies, specifically labs.

606
00:31:01,209 --> 00:31:04,719
So this isn't gonna be a
major surprise to anyone.

607
00:31:04,719 --> 00:31:06,369
We order a bunch of labs in the ED.

608
00:31:06,589 --> 00:31:09,439
So you're gonna get your
routine labs, so your CBC your

609
00:31:09,439 --> 00:31:11,089
chemistry, your renal function.

610
00:31:11,329 --> 00:31:15,589
It is helpful to get coagulation
studies if you know they have a

611
00:31:15,589 --> 00:31:18,719
history of cirrhosis or if they look
like they're cirrhotic because that

612
00:31:18,719 --> 00:31:22,229
can help you gauge how far along
in their liver disease they are.

613
00:31:22,509 --> 00:31:25,389
You should expect to see
things like thrombocytopenia

614
00:31:25,389 --> 00:31:28,329
and anemia and leukopenia.

615
00:31:28,329 --> 00:31:32,629
So, low white blood cell count, low
hemoglobin, low platelet count in your

616
00:31:32,629 --> 00:31:34,819
chronic alcoholics is pretty common.

617
00:31:35,039 --> 00:31:39,599
You can actually get an elevated white
blood cell count from things like alcohol

618
00:31:39,599 --> 00:31:44,199
withdrawal seizures but just know there's
a lot of overlap here with other diseases,

619
00:31:44,199 --> 00:31:47,079
so you can't rely on that for anything.

620
00:31:47,299 --> 00:31:48,769
But there are some things that are common.

621
00:31:49,244 --> 00:31:52,214
An alcohol level is also helpful,
especially if there's any question

622
00:31:52,214 --> 00:31:55,334
about whether or not the person's
intoxicated versus in true withdrawal.

623
00:31:55,694 --> 00:32:00,584
There are chronic alcoholics who
will begin to withdraw long before

624
00:32:00,584 --> 00:32:02,444
their alcohol level reaches zero.

625
00:32:03,144 --> 00:32:07,354
So we've all seen those people, we know
them well, and that's treated clinically.

626
00:32:07,354 --> 00:32:11,104
So don't be afraid to begin the benzos
early or if they're gonna go home, you

627
00:32:11,104 --> 00:32:13,624
know, discharge them as soon as they're
clinically sober so that they don't

628
00:32:13,624 --> 00:32:14,854
withdraw in your emergency department.

629
00:32:15,244 --> 00:32:17,444
And then testing for co-ingestions.

630
00:32:17,464 --> 00:32:22,244
So aspirin, Tylenol a drug screen,
which you know, is universally not

631
00:32:22,244 --> 00:32:24,764
great, but better than nothing can
sometimes tell you if there's some

632
00:32:24,764 --> 00:32:28,424
sympathomimetics on board, some cocaine,
some amphetamines, anything else that

633
00:32:28,424 --> 00:32:29,864
might be altering their vital signs.

634
00:32:29,864 --> 00:32:31,004
So all of that is helpful.

635
00:32:31,704 --> 00:32:35,794
An EKG is very helpful especially
if they have severe electrolyte

636
00:32:35,794 --> 00:32:39,094
deficiencies to take a look at their
QT intervals, because things that

637
00:32:39,094 --> 00:32:43,144
are seizures or things that look like
seizures may not always be seizures.

638
00:32:43,334 --> 00:32:45,554
And so you can get arrhythmias
that's pretty common.

639
00:32:45,684 --> 00:32:47,994
Atrial fibrillation probably
being one of the most common.

640
00:32:48,537 --> 00:32:49,677
And then there's imaging.

641
00:32:49,767 --> 00:32:54,007
So chest x-ray is indicated
if there's hypoxia or fever or

642
00:32:54,007 --> 00:32:55,357
any kind of chest discomfort.

643
00:32:55,784 --> 00:32:59,264
CT imaging of the brain is certainly
indicated if they have alterations

644
00:32:59,264 --> 00:33:02,174
in their mental status or seizures
or evidence of head trauma.

645
00:33:02,414 --> 00:33:06,164
And so those are probably
pretty routine for most of us

646
00:33:06,164 --> 00:33:07,214
in the emergency department.

647
00:33:07,914 --> 00:33:09,009
T.R. Eckler: Any suspicion for trauma?

648
00:33:09,009 --> 00:33:12,249
I would say I'm adding a CT of their
cervical spine to that as well, because

649
00:33:12,249 --> 00:33:15,969
I've seen plenty of those kind of traumas
where they've got multiple injuries.

650
00:33:16,059 --> 00:33:18,879
And then I think this article
convinced me I need to be thinking

651
00:33:18,879 --> 00:33:20,349
more about an ammonia level.

652
00:33:20,569 --> 00:33:24,319
I think that more of these, you
know, sicker, older alcoholics, I

653
00:33:24,319 --> 00:33:27,679
need to be aware that their liver
can be failing and there can be some

654
00:33:27,679 --> 00:33:29,209
degree of hepatic encephalopathy.

655
00:33:29,389 --> 00:33:32,209
So I think that's something to
help my colleagues upstairs as

656
00:33:32,209 --> 00:33:34,639
to give them a starting point as
to where their ammonia level is.

657
00:33:35,156 --> 00:33:35,661
Sam: Yeah, for sure.

658
00:33:35,946 --> 00:33:37,386
Point of care glucose is another one.

659
00:33:37,386 --> 00:33:41,866
You know, we mentioned hypoglycemia but
they can get alcohol ketoacidosis and get

660
00:33:42,016 --> 00:33:44,806
pretty significant acidosis and you're
gonna give 'em fluids and then you're

661
00:33:44,806 --> 00:33:49,886
gonna give them IV D 10 or infusions
of some kind of glucose solution.

662
00:33:49,886 --> 00:33:51,186
And you wanna give them the thiamine.

663
00:33:51,396 --> 00:33:54,426
And so when we get into the meds, we'll
talk about all of that, but just know

664
00:33:54,426 --> 00:33:56,206
that those are pretty common derangements.

665
00:33:56,226 --> 00:33:57,796
We're gonna see hypo mag.

666
00:33:57,796 --> 00:34:00,376
If there's not a magnesium included
in your chemistry profile, you're

667
00:34:00,376 --> 00:34:01,486
gonna want a magnesium level.

668
00:34:01,486 --> 00:34:06,776
So it's not a sparing approach to
testing for this patient population.

669
00:34:07,436 --> 00:34:10,256
T.R. Eckler: I really try to look at
their anion gap because if there's

670
00:34:10,256 --> 00:34:13,646
really a metabolic acidosis there and
it's significant, and I don't think

671
00:34:13,646 --> 00:34:17,096
it's because of lactic or I don't think
it's because of alcoholic ketoacidosis,

672
00:34:17,396 --> 00:34:19,106
then is there a toxic alcohol there?

673
00:34:19,286 --> 00:34:21,926
And I think this is a group that I'm
always trying to catch, like did they

674
00:34:21,926 --> 00:34:25,316
get into something else while they were
drinking and is there something else I

675
00:34:25,316 --> 00:34:28,766
need to be worried about that they might
need, you know, dialysis for or something

676
00:34:28,766 --> 00:34:32,096
to clear because the earlier you get to
that answer, the better it's gonna be.

677
00:34:32,096 --> 00:34:35,996
So I try to keep that high index of
suspicion for, we're looking at labs

678
00:34:35,996 --> 00:34:38,486
for these patients to really kind
of see what it looks like and then

679
00:34:38,486 --> 00:34:41,876
considering further workup or talking
to poison control if I've got concerns.

680
00:34:42,576 --> 00:34:44,526
Sam: All right, let's get into treatment.

681
00:34:44,556 --> 00:34:48,546
So we talked already about that
kindling effect, where repeated cycles

682
00:34:48,546 --> 00:34:53,796
of withdrawal and intoxication kinda
heightened their CNS hyperexcitability

683
00:34:53,796 --> 00:34:56,766
and cause longer duration and
severity of withdrawal symptoms.

684
00:34:56,766 --> 00:35:00,036
And so they may need escalating
doses of medications.

685
00:35:00,316 --> 00:35:03,556
So be alert to the fact that this
may not be their first presentation.

686
00:35:03,896 --> 00:35:08,816
the really mainstay of treatment here
is decreasing overall stimulation.

687
00:35:08,816 --> 00:35:12,416
'cause this is what the alcohol was
doing before it went away, and this is

688
00:35:12,416 --> 00:35:14,216
what their brain has been accustomed to.

689
00:35:14,426 --> 00:35:19,706
And the mainstay for doing
that is still benzodiazepines.

690
00:35:19,736 --> 00:35:21,986
And we'll talk more about other
options here in just a second.

691
00:35:21,986 --> 00:35:24,576
But the benzodiazepines are well studied.

692
00:35:24,576 --> 00:35:28,986
There's a good volume of evidence behind
them, especially in this population.

693
00:35:29,146 --> 00:35:31,036
Not necessarily specific to one agent.

694
00:35:31,036 --> 00:35:34,216
It started back in the
1960s with chlordiazepoxide.

695
00:35:34,406 --> 00:35:36,146
This is oral Librium therapy.

696
00:35:36,336 --> 00:35:40,806
And so there's a large volume of
evidence behind that particular therapy.

697
00:35:41,689 --> 00:35:42,259
T.R. Eckler: OG Baby.

698
00:35:42,544 --> 00:35:42,724
Sam: Yeah.

699
00:35:42,769 --> 00:35:44,689
T.R. Eckler: Nobody ever
asks for a refill on Librium.

700
00:35:44,869 --> 00:35:46,759
It works and it isn't awesome.

701
00:35:47,299 --> 00:35:48,499
Sam: It, it does very well.

702
00:35:48,779 --> 00:35:52,559
The other benzodiazepines in this
category include things like diazepam,

703
00:35:52,559 --> 00:35:56,369
which is rather long acting with
a half-life of 20 to 80 hours.

704
00:35:56,639 --> 00:35:59,909
Lorazepam, which is much
shorter acting 10 to 20 hours.

705
00:36:00,239 --> 00:36:03,059
Midazolam, which is the shortest
acting, that's six hours.

706
00:36:03,299 --> 00:36:06,389
And then chlordiazepoxide,
which is anywhere from 24 to

707
00:36:06,389 --> 00:36:08,669
84 hours, but is oral only.

708
00:36:08,909 --> 00:36:15,419
And so those four benzodiazepines make
up the bulk of therapy, and there are

709
00:36:15,419 --> 00:36:17,549
multiple ways to go about doing this.

710
00:36:17,599 --> 00:36:22,439
I like that the author recommended a
pretty liberal approach to medicating

711
00:36:22,439 --> 00:36:26,159
patients, especially as they first start
to develop symptoms, kind of getting on

712
00:36:26,159 --> 00:36:29,969
top of them early, not having to wait
until they're in full blown withdrawal

713
00:36:29,969 --> 00:36:33,359
because then you're catching up and
somebody who might have even been able

714
00:36:33,359 --> 00:36:37,799
to go home is now stuck maybe having
to go inpatient or even to the ICU.

715
00:36:37,859 --> 00:36:41,339
So it is important to recognize
it and recognize it early.

716
00:36:41,529 --> 00:36:46,149
Nowadays in the era of medication
shortage, you may not have the

717
00:36:46,149 --> 00:36:50,139
luxury of deciding between these
agents, and so just know that the

718
00:36:50,139 --> 00:36:52,029
chlordiazepoxide is oral only.

719
00:36:52,029 --> 00:36:55,779
So that leaves you with only
three IV options, midazolam,

720
00:36:55,779 --> 00:36:57,099
lorazepam, and diazepam.

721
00:36:57,099 --> 00:37:01,249
And if given the option between
the three diazepam is the longest

722
00:37:01,454 --> 00:37:07,714
acting, but also has some hepatic
metabolism that has to be occurred in

723
00:37:07,714 --> 00:37:09,184
order to clear it from your system.

724
00:37:09,184 --> 00:37:12,244
So if you've got somebody who's
cirrhotic, it's gonna be on board for

725
00:37:12,244 --> 00:37:13,984
a little longer maybe than you intend.

726
00:37:14,234 --> 00:37:17,884
Lorazepam does not undergo
the same hepatic metabolism.

727
00:37:17,884 --> 00:37:20,344
It only undergoes the phase
two hepatic metabolism.

728
00:37:20,344 --> 00:37:23,604
So it's gonna be eliminated
mostly by the kidneys and it

729
00:37:23,604 --> 00:37:25,644
may be more reliable for dosing.

730
00:37:25,894 --> 00:37:28,954
Midazolam works great for IM,
if you don't have an IV yet, and

731
00:37:28,954 --> 00:37:29,884
we've already mentioned that.

732
00:37:30,164 --> 00:37:34,004
So there are some nuances to medications,
but by and large it's gonna be,

733
00:37:34,004 --> 00:37:37,274
you know, what do you have and what
do you have in large quantities?

734
00:37:37,274 --> 00:37:42,734
Because depending on how sick they are,
these patients can take anywhere from like

735
00:37:42,884 --> 00:37:45,944
triple digits to four digit milligrams.

736
00:37:46,164 --> 00:37:49,884
We're talking about grams of
medication to get symptomatic control.

737
00:37:50,074 --> 00:37:52,714
And over the course of days
in the ICU, they run through

738
00:37:52,714 --> 00:37:54,424
massive quantities of medication.

739
00:37:54,664 --> 00:37:58,324
And so when it comes to benzodiazepines,
it's going to be give it, give it

740
00:37:58,324 --> 00:38:02,954
early be liberal, but know that
yes, there are some side effects.

741
00:38:02,984 --> 00:38:06,014
You know, sedation probably being
the one people worry about the most.

742
00:38:06,314 --> 00:38:09,877
But it's not a reason to
withhold therapy by any means.

743
00:38:10,543 --> 00:38:14,068
T.R. Eckler: I would say the state in
our shop right now is such that we only

744
00:38:14,068 --> 00:38:18,598
have versed, we have very, very limited,
if not non-existent supplies of Valium

745
00:38:18,598 --> 00:38:21,108
and Ativan or diazepam and Lorazepam.

746
00:38:21,498 --> 00:38:27,438
So essentially we're, you know, giving
Midazolam when it's indicated, but then

747
00:38:27,438 --> 00:38:32,958
we're moving to oral or other strategies
like our next topic of Gabapentin because

748
00:38:33,108 --> 00:38:37,858
there's just such a need to preserve
our benzo supply of what we can to have

749
00:38:37,858 --> 00:38:40,918
it not just for these patients, but
for our patients with agitated delirium

750
00:38:41,158 --> 00:38:44,338
or other patients that need sedation
or for our pediatric seizure patients.

751
00:38:44,887 --> 00:38:45,967
Sam: Yeah, great point.

752
00:38:45,967 --> 00:38:49,117
And there are some shops that have
converted to phenobarbital exclusively.

753
00:38:49,117 --> 00:38:51,577
It's just their first level
medication that they're giving

754
00:38:51,577 --> 00:38:54,217
initially, and they're not even
discussing benzodiazepines anymore.

755
00:38:54,467 --> 00:38:56,297
And we'll get into that in two seconds.

756
00:38:56,297 --> 00:38:59,687
First, a trivia question, in
which situation is Lorazepam

757
00:38:59,687 --> 00:39:02,842
preferred over diazepam for
treatment of alcohol withdrawal?

758
00:39:03,172 --> 00:39:08,572
In patients with mild withdrawal symptoms,
in patients requiring IM medication, in

759
00:39:08,572 --> 00:39:13,162
patients with end stage liver disease,
in patients with a history of epilepsy,

760
00:39:13,312 --> 00:39:14,872
or in patients with hypotension.

761
00:39:15,572 --> 00:39:17,722
T.R. Eckler: C you don't want
to give it to the cirrhotics.

762
00:39:18,094 --> 00:39:18,424
Sam: That's right.

763
00:39:18,664 --> 00:39:19,054
That's right.

764
00:39:19,174 --> 00:39:24,984
Only because lorazepam, like I said
before only has phase two liver metabolism

765
00:39:24,984 --> 00:39:28,224
while diazepam does have to go through
the full liver metabolism and it can

766
00:39:28,224 --> 00:39:30,924
hang around a lot longer than intended.

767
00:39:31,204 --> 00:39:34,474
Again, if that's all you have,
don't withhold it because of that.

768
00:39:34,624 --> 00:39:37,924
But if you have the luxury of choosing
between the two and you know the

769
00:39:37,924 --> 00:39:40,864
person has end stage liver disease,
you're headed for the Lorazepam.

770
00:39:41,564 --> 00:39:43,124
All right, let's dive into phenobarbital.

771
00:39:43,244 --> 00:39:47,874
So phenobarbital has been around
for a very long time and it is a

772
00:39:47,874 --> 00:39:53,084
medication that was used for alcohol
withdrawal, then was kind of dropped

773
00:39:53,084 --> 00:39:56,354
and we went to benzodiazepines and
now it's kind of making a resurgence.

774
00:39:56,544 --> 00:40:00,114
It's in the category of medications
called barbiturates and it has a distinct

775
00:40:00,114 --> 00:40:02,244
binding site on that GABA A receptor.

776
00:40:02,554 --> 00:40:04,564
And it increases chloride influx.

777
00:40:04,564 --> 00:40:07,084
And I don't wanna get too deep
into the physiology of it,

778
00:40:07,084 --> 00:40:08,524
but just know that it works.

779
00:40:08,614 --> 00:40:12,754
But it works by a secondary mechanism,
so it has a different pathway

780
00:40:12,754 --> 00:40:14,494
than your typical benzodiazepine.

781
00:40:14,744 --> 00:40:20,594
And it can result in symptomatic
control for much longer periods,

782
00:40:20,594 --> 00:40:24,344
we're talking like half life
of 120 hours, and the tapering

783
00:40:24,344 --> 00:40:26,174
effect from a single loading dose.

784
00:40:26,354 --> 00:40:30,694
And so you can get more or less what
some people have described, ideal

785
00:40:30,694 --> 00:40:35,884
alcohol withdrawal coverage that lasts
multiple days and then gradually tapers

786
00:40:35,884 --> 00:40:39,724
off without having to give somebody
a prescription for a Librium or give

787
00:40:39,724 --> 00:40:41,704
them multiple doses of benzodiazepines.

788
00:40:41,824 --> 00:40:44,704
You can just load them once and
then as soon as they're clinically

789
00:40:44,704 --> 00:40:46,084
sober, discharge them home.

790
00:40:46,304 --> 00:40:50,804
And many centers have converted to
that as being their first line therapy.

791
00:40:51,224 --> 00:40:52,364
You use much phenobarbital?

792
00:40:52,724 --> 00:40:55,724
T.R. Eckler: This is the biggest change
in my practice in the last five years.

793
00:40:55,724 --> 00:40:59,414
I would tell you that because of
shortages and because of just the

794
00:40:59,414 --> 00:41:02,654
severity of some of the patients that
we've seen and the fact that now I'm

795
00:41:02,654 --> 00:41:06,324
not transferring them out, they're
staying in my shop compared with like my

796
00:41:06,324 --> 00:41:09,324
rural times where a lot of times these
patients would be getting transferred.

797
00:41:09,684 --> 00:41:13,344
I am giving a lot more phenobarbital,
both for patients getting admitted

798
00:41:13,614 --> 00:41:16,804
and patients that are getting
discharged because as you said, I

799
00:41:16,804 --> 00:41:18,844
think it gives me guaranteed control.

800
00:41:18,994 --> 00:41:22,924
It really stabilizes the patient
in a really reliable way.

801
00:41:23,284 --> 00:41:27,244
And it doesn't preclude you then from
giving other medication on top of

802
00:41:27,244 --> 00:41:31,234
that, whether that's a little more
phenobarbital or benzos or something else.

803
00:41:31,384 --> 00:41:33,994
But it's gonna decrease the
total amount you're gonna need of

804
00:41:33,994 --> 00:41:36,004
anything else by a dramatic amount.

805
00:41:36,244 --> 00:41:39,274
And I think that, especially when
I'm, you know, admitting to a very

806
00:41:39,274 --> 00:41:40,984
busy hospital, the hospital's full.

807
00:41:40,984 --> 00:41:43,114
I'm worried when the inpatient
team is gonna get to some of

808
00:41:43,114 --> 00:41:44,194
the patients or this or that.

809
00:41:44,324 --> 00:41:48,564
I find that taking control of these
situations is with the phenobarbital

810
00:41:48,584 --> 00:41:51,674
load in the emergency room, especially
given that we have great ER pharmacists

811
00:41:51,674 --> 00:41:55,064
that help us to administer it it's
a great tool to have and it has

812
00:41:55,064 --> 00:41:59,054
completely from when I was in residency
and in the rural places to now I've

813
00:41:59,084 --> 00:42:03,164
completely gone a 180 on it because I
used to say, ah, no, I'm a Valium guy.

814
00:42:03,164 --> 00:42:04,124
I'm from New York City.

815
00:42:04,124 --> 00:42:07,934
That's what we do, and now I really have
started to lead with this more and more.

816
00:42:08,264 --> 00:42:12,134
I find it especially really helpful in
the kind of patient that's, you know,

817
00:42:12,224 --> 00:42:15,614
not sick from alcohol, but sick from
something else, like say an aspiration

818
00:42:15,614 --> 00:42:19,694
pneumonia or COVID or flu, and they're
a little hypoxic and they look unwell.

819
00:42:19,934 --> 00:42:24,254
Giving them a loading dose of
phenobarbital often stabilizes them in a

820
00:42:24,254 --> 00:42:29,534
way that gives them a chance to like cool
off and calm down without you constantly

821
00:42:29,534 --> 00:42:33,164
debating of, should I give this patient
benzos when they need oxygen already?

822
00:42:33,344 --> 00:42:35,354
I'm worried about the
oxygen demand getting worse.

823
00:42:35,504 --> 00:42:38,924
It gives you a chance to treat one
problem and then move on and focus

824
00:42:38,924 --> 00:42:41,954
on the next one, and then if they
get worse, you know that it's because

825
00:42:41,954 --> 00:42:42,774
that's what you need to work on.

826
00:42:43,474 --> 00:42:45,374
Sam: Yeah, that's
perfectly said right there.

827
00:42:45,434 --> 00:42:47,654
there is some evidence
behind phenobarbital.

828
00:42:47,714 --> 00:42:52,154
There's very little comparing head to
head phenobarb versus benzodiazepine.

829
00:42:52,154 --> 00:42:55,864
So there was one study cited
by the author a prospective

830
00:42:55,864 --> 00:42:57,664
randomized trial, 44 patients.

831
00:42:57,664 --> 00:43:01,354
So very small comparing lorazepam to
phenobarb and it showed no difference in

832
00:43:01,354 --> 00:43:04,804
the mild to moderate alcohol withdrawal
syndrome as far as admission rates.

833
00:43:04,964 --> 00:43:07,749
Follow up CIWA scores at
48 hours from discharge.

834
00:43:08,349 --> 00:43:10,359
That at least is one comparison study.

835
00:43:10,359 --> 00:43:12,369
There's lots of clinical anecdotes.

836
00:43:12,529 --> 00:43:16,669
There was one meta-analysis of 12
studies, so that's a total combined

837
00:43:16,669 --> 00:43:22,219
population of almost 2000 patients
that compared benzos to phenobarbital

838
00:43:22,399 --> 00:43:27,049
and showed there was no differences
in the rate of intubation, seizures,

839
00:43:27,109 --> 00:43:29,719
hospitalization, and ICU length of stay.

840
00:43:29,989 --> 00:43:35,099
But also there are now some
double-blinded, randomized placebo

841
00:43:35,099 --> 00:43:40,529
controlled trials that compare benzos
only to benzos plus phenobarbital.

842
00:43:41,069 --> 00:43:44,219
And found that those treated with
phenobarbital had significantly lower

843
00:43:44,219 --> 00:43:49,109
rates of ICU admission compared to
placebo, but also highlighting that if

844
00:43:49,109 --> 00:43:53,669
they had phenobarb plus benzodiazepines,
they fared better than just benzos alone.

845
00:43:53,729 --> 00:43:59,749
So it is now something that is being
recommended as a reasonable alternative

846
00:43:59,969 --> 00:44:02,129
by a lot of clinical practice guidelines.

847
00:44:02,129 --> 00:44:06,189
The ASAM, A-S-A-M, the GRACE four
trial and recommendations, and

848
00:44:06,189 --> 00:44:09,489
the Society for Academic Emergency
Medicine, all of them are recommending

849
00:44:09,489 --> 00:44:13,269
these as potential alternative
therapies or adjuncts to first line.

850
00:44:13,329 --> 00:44:16,763
So you can certainly replace them if
you're comfortable or if that's become

851
00:44:16,763 --> 00:44:18,413
the standard protocol in your shop.

852
00:44:18,773 --> 00:44:19,313
Great.

853
00:44:19,503 --> 00:44:23,263
Just make sure that you have some kind
of protocolized approach and that you

854
00:44:23,263 --> 00:44:24,403
know, everybody's on the same page.

855
00:44:24,403 --> 00:44:25,633
That yes, this is what we're doing.

856
00:44:25,883 --> 00:44:30,233
The loading dose is 10 milligrams per
kilo IV given over about 30 minutes,

857
00:44:30,493 --> 00:44:31,883
T.R. Eckler: That's
ideal body weight though.

858
00:44:31,883 --> 00:44:35,195
You gotta make sure you're basing it
off their ideal body weight because not

859
00:44:35,195 --> 00:44:36,785
everyone is at their ideal body weight.

860
00:44:37,485 --> 00:44:39,930
Sam (2): I have no idea what
you're talking about, sir. Yes,

861
00:44:39,990 --> 00:44:40,830
thank you for that correction.

862
00:44:40,830 --> 00:44:45,060
10 milligrams per kilo of ideal
body weight, or you can give 260

863
00:44:45,060 --> 00:44:48,690
milligrams IV over five minutes
for moderate symptoms, just as a

864
00:44:48,690 --> 00:44:50,755
one time non-weight based dosing.

865
00:44:50,995 --> 00:44:54,595
And then subsequent dosing
can occur every 30 minutes as

866
00:44:54,595 --> 00:44:59,085
needed until you get symptomatic
relief up to a gram in 24 hours.

867
00:44:59,085 --> 00:45:01,155
So you can get pretty high doses.

868
00:45:01,315 --> 00:45:04,018
And the most important thing
to remember is that this is a

869
00:45:04,018 --> 00:45:05,218
kind of a one and done thing.

870
00:45:05,218 --> 00:45:08,438
Once you get them loaded and
they've achieved control they're

871
00:45:08,438 --> 00:45:10,358
good for up to 120 hours.

872
00:45:10,358 --> 00:45:14,738
So you know, if they have appropriate
control of symptoms, normal vital

873
00:45:14,738 --> 00:45:18,338
signs are awake and alert and aren't
really sedated by this medication.

874
00:45:18,338 --> 00:45:19,358
This is somebody who could go home.

875
00:45:19,868 --> 00:45:23,268
Somebody who you would've previously
given a prescription to for Librium

876
00:45:23,478 --> 00:45:25,968
and said, this is how I want you
to taper over the next few days.

877
00:45:26,118 --> 00:45:29,928
This kind of is on automatic taper
as they metabolize it, and they

878
00:45:29,928 --> 00:45:31,128
don't have to worry about it anymore.

879
00:45:31,138 --> 00:45:32,758
The patient does have to be reliable.

880
00:45:32,818 --> 00:45:35,908
You know, they're supposed to not go
and drink alcohol during this time

881
00:45:35,908 --> 00:45:39,058
period, just like they would if it
was Librium or some other benzo.

882
00:45:39,268 --> 00:45:41,758
So you do have to select
your patient appropriately.

883
00:45:42,068 --> 00:45:45,758
And know that the typical side effects
for phenobarb are pretty much the same

884
00:45:45,758 --> 00:45:46,868
things you're gonna get from benzos.

885
00:45:46,868 --> 00:45:50,258
We're talking respiratory
depression and over sedation.

886
00:45:50,478 --> 00:45:54,498
It does have kind of a narrow therapeutic
window, which means there's a little

887
00:45:54,748 --> 00:45:58,618
more rapid progression from, you know,
normal to sedated as you're giving it.

888
00:45:58,808 --> 00:46:03,518
But once you get used to it and you've
become someone who uses it more frequently

889
00:46:03,648 --> 00:46:05,268
you'll get comfortable with that dosing.

890
00:46:05,458 --> 00:46:08,038
And a protocolized approach
is really the best way to go.

891
00:46:08,679 --> 00:46:11,330
T.R. Eckler (2): 10 milligrams Per
kilogram ideal body weight over 30

892
00:46:11,330 --> 00:46:14,175
minutes is what we're using in our shop,
and I've had tons of success with it.

893
00:46:14,570 --> 00:46:17,660
I find that sometimes then afterwards, if
the patient's still a little anxious, I'll

894
00:46:17,660 --> 00:46:19,280
give them a little bit of Valium as well.

895
00:46:19,400 --> 00:46:21,410
'cause sometimes I think
they think they need it.

896
00:46:21,710 --> 00:46:24,890
But I think once you let this really
kick in, the patients do great.

897
00:46:25,040 --> 00:46:28,640
I think my one caveat for these patients
is you don't wanna use this in that

898
00:46:28,640 --> 00:46:32,360
really sick, really altered, you know,
delirium, tremons patient if you really

899
00:46:32,360 --> 00:46:36,410
think they're heading for the ICU, because
I think that those kind of patients you

900
00:46:36,410 --> 00:46:40,080
might wanna consider propofol, precedex,
something that's a little more short

901
00:46:40,080 --> 00:46:41,880
acting that you can adjust more carefully.

902
00:46:42,090 --> 00:46:44,580
And I've gotten support for
that from my ICU colleagues.

903
00:46:44,760 --> 00:46:46,890
I think that kind of
varies from shop to shop.

904
00:46:46,890 --> 00:46:50,040
So I think that's worth a discussion
between the ER and the, you

905
00:46:50,040 --> 00:46:51,810
know, medicine and the ICU teams.

906
00:46:51,990 --> 00:46:55,920
But I think that that's an area that we're
still trying to work out kind of exactly

907
00:46:55,920 --> 00:47:01,460
which patients do best with phenobarbital
versus precedex versus propofol and benzos

908
00:47:01,460 --> 00:47:04,670
and kind of what the right mixture is
for the really, really sick patients.

909
00:47:05,234 --> 00:47:05,404
Sam: Yeah.

910
00:47:05,644 --> 00:47:07,114
Yeah, that's another great point.

911
00:47:07,114 --> 00:47:10,234
If they're already headed to the ICU
and you're not trying to just prevent

912
00:47:10,234 --> 00:47:13,574
that, then certainly a conversation
with your intensivists about what

913
00:47:13,574 --> 00:47:17,014
their preferences are  is due in
advance of the patient presentation.

914
00:47:17,714 --> 00:47:19,214
There are some adjunctive therapies.

915
00:47:19,214 --> 00:47:20,684
So we mentioned thiamine.

916
00:47:20,814 --> 00:47:25,004
All of these patients are going to be,
you know vitamin deficient and are gonna

917
00:47:25,004 --> 00:47:28,304
need thiamine, and most of them are gonna
end up on some kind of glucose solution.

918
00:47:28,464 --> 00:47:31,104
The ideal timing is to
give the thiamine first.

919
00:47:31,264 --> 00:47:34,834
But if they're hypoglycemic, you're
not gonna withhold the glucose in

920
00:47:34,834 --> 00:47:36,334
order to give them the thymine first.

921
00:47:36,464 --> 00:47:39,684
You could certainly start it and then
give the thiamine and it's okay to

922
00:47:39,684 --> 00:47:41,454
give them simultaneously as well.

923
00:47:41,454 --> 00:47:43,654
So they're definitely gonna
be thiamine deficient.

924
00:47:43,654 --> 00:47:47,104
The standard dose is a hundred
milligrams IV, but if they have

925
00:47:47,104 --> 00:47:51,604
symptoms like nystagmus or ataxia
or confusion, those are the symptoms

926
00:47:51,604 --> 00:47:53,104
of Wernicke's encephalopathy.

927
00:47:53,264 --> 00:47:57,039
Most people will have
not all three of these.

928
00:47:57,169 --> 00:48:00,829
So you know, only 10% of the population
who actually has Wernicke's encephalopathy

929
00:48:00,839 --> 00:48:02,039
will show all three of these.

930
00:48:02,189 --> 00:48:06,659
But that's kind of the, the textbook
triad nystagmus, ataxia and confusion.

931
00:48:06,879 --> 00:48:09,879
If they are already presenting with
those, then you're talking about larger

932
00:48:09,879 --> 00:48:12,379
doses, like 500 milligrams IV of thiamine.

933
00:48:12,649 --> 00:48:15,739
But the standard dose is a hundred
IV and you give it hopefully before

934
00:48:15,739 --> 00:48:17,209
you start your dextrose solution

935
00:48:17,579 --> 00:48:19,932
T.R. Eckler (2): I've had one round
of high dose thiamine basically

936
00:48:19,932 --> 00:48:22,602
cure a patient right on the spot,
like over the course of an hour.

937
00:48:22,822 --> 00:48:27,781
A man came in, just bumbling and
really just in a rough state.

938
00:48:27,781 --> 00:48:30,691
And he'd been like that for a few
days and his wife just said, well,

939
00:48:30,691 --> 00:48:32,071
I thought he was gonna get better.

940
00:48:32,251 --> 00:48:34,631
And I was like, you know, I
really think this is Wernicke's.

941
00:48:34,651 --> 00:48:37,741
And I gave him 500 of thiamine and
over the course of an hour or two, he

942
00:48:37,741 --> 00:48:41,551
came around and was his normal self
again and talking and everything else.

943
00:48:41,611 --> 00:48:44,941
And I was pretty excited to get him
admitted for a couple of days of thiamine

944
00:48:45,121 --> 00:48:46,441
and making sure he didn't progress.

945
00:48:46,441 --> 00:48:49,321
But it was one of those rare
moments where the family, looks

946
00:48:49,321 --> 00:48:51,061
at you and goes, what did you do?

947
00:48:51,061 --> 00:48:54,351
And you say, ah, you know,
had a thought, had a hunch.

948
00:48:54,841 --> 00:48:56,051
Sam: House MD. That's right.

949
00:48:56,641 --> 00:48:57,184
TR Eckler.

950
00:48:57,884 --> 00:48:59,354
Well done, sir. Well done.

951
00:49:00,054 --> 00:49:03,934
And then the author does talk about
like we mentioned before kind of this

952
00:49:03,934 --> 00:49:10,534
risk-based strategy for potentially
loading someone in advance of symptoms.

953
00:49:10,534 --> 00:49:12,664
So someone you know is going to withdraw.

954
00:49:12,694 --> 00:49:15,874
You know that they're going to be there
longer than they want to be, you know

955
00:49:15,874 --> 00:49:17,224
that they're gonna start withdrawing.

956
00:49:17,474 --> 00:49:22,214
There is benefit shown to starting that
benzodiazepine therapy early opposed

957
00:49:22,214 --> 00:49:23,894
to waiting until they're in withdrawal.

958
00:49:24,114 --> 00:49:26,184
So you can then not have to play catchup.

959
00:49:26,783 --> 00:49:30,123
T.R. Eckler: Have a brief moment of
we need to modernize something for the

960
00:49:30,123 --> 00:49:32,283
modern age, the cage questionnaire.

961
00:49:32,283 --> 00:49:35,373
I remember being taught about the cage
questionnaire in medical school and

962
00:49:35,373 --> 00:49:39,633
I thought it was the judgiest worst
questionnaire I had ever encountered.

963
00:49:39,843 --> 00:49:44,313
And I stand by that 20 years later
that this thing needs to be changed.

964
00:49:44,703 --> 00:49:49,113
I think we need to sit down and come up
with something that's got a better name.

965
00:49:49,593 --> 00:49:50,673
You can't call it the cage.

966
00:49:50,673 --> 00:49:51,633
That sounds like a trap.

967
00:49:51,663 --> 00:49:55,113
'cause it's a trap you gotta come up
with something that makes it cool.

968
00:49:55,113 --> 00:49:57,873
It's like that Saturday Night Live
skit they did where they was like, you

969
00:49:57,873 --> 00:50:01,773
know, interviewing guys on a podcast is
how they do their medical visits now.

970
00:50:01,953 --> 00:50:04,203
Like that's what I think we need is
some kind of thing where it's like,

971
00:50:04,323 --> 00:50:06,223
hey, do you like to party great?

972
00:50:06,273 --> 00:50:07,473
How much do you like to party?

973
00:50:07,473 --> 00:50:09,483
Do you need to like, have
something to drink after you've

974
00:50:09,483 --> 00:50:10,413
had a big night of partying?

975
00:50:10,463 --> 00:50:13,103
We gotta work on the way that
questionnaire works to make it

976
00:50:13,103 --> 00:50:14,903
not seem so much like it's a trap.

977
00:50:15,253 --> 00:50:15,543
Sam: Yeah.

978
00:50:15,733 --> 00:50:16,738
Yeah, that's fair.

979
00:50:16,796 --> 00:50:18,866
T.R. Eckler: I stand in opposition
to the cage questionnaire.

980
00:50:19,406 --> 00:50:24,416
Sam: If you're listening, CAGE stands
for cut, annoyed, guilty and eyeopener.

981
00:50:24,576 --> 00:50:29,589
And it's a questionnaire that's meant
to kinda gauge where they are on their

982
00:50:29,689 --> 00:50:34,179
propensity for alcohol withdrawal
because it can affect you know, your

983
00:50:34,179 --> 00:50:37,539
suspicion for alcohol withdrawal or
developing alcohol withdrawal syndrome.

984
00:50:37,699 --> 00:50:42,259
And there actually is pretty decent
evidence behind the questionnaire and

985
00:50:42,289 --> 00:50:46,339
how early administration of lorazepam
in high risk patients on the cage

986
00:50:46,339 --> 00:50:47,989
questionnaire can decrease length of stay.

987
00:50:48,139 --> 00:50:50,939
So it is a helpful questionnaire,
but I agree with you.

988
00:50:50,939 --> 00:50:53,939
The acronym does sound
a little sanctimonious

989
00:50:54,085 --> 00:50:55,115
T.R. Eckler: There's PAWSS.

990
00:50:55,135 --> 00:50:57,750
I like, 'cause I'm just trying to
see how much of an animal you are.

991
00:50:57,750 --> 00:50:59,410
Like maybe you got some big paws.

992
00:50:59,430 --> 00:51:00,180
That's okay.

993
00:51:00,700 --> 00:51:03,740
I'm just trying to make sure that I
take the best care of you as I can.

994
00:51:03,740 --> 00:51:04,135
That's what I'm here for.

995
00:51:04,951 --> 00:51:05,341
Sam: right.

996
00:51:06,041 --> 00:51:08,951
On that note, let's move on
to anti-seizure medication.

997
00:51:09,371 --> 00:51:11,901
All I gotta say about
that is just don't do it.

998
00:51:12,122 --> 00:51:12,342
T.R. Eckler: No,

999
00:51:13,205 --> 00:51:13,745
Sam: It doesn't work.

1000
00:51:14,105 --> 00:51:14,735
It does not work.

1001
00:51:14,881 --> 00:51:17,361
T.R. Eckler: Unless they have head
bleed, then we can talk about it.

1002
00:51:17,525 --> 00:51:19,835
Sam: Okay, then you're gonna treat their
alcohol withdrawal and they're probably

1003
00:51:19,835 --> 00:51:21,635
gonna get dual coverage from that anyway.

1004
00:51:21,635 --> 00:51:26,465
But anti-seizure medications uniformly
fail when compared with benzodiazepines.

1005
00:51:26,465 --> 00:51:30,515
That's a direct quote from the article and
pretty much all we need to say about that.

1006
00:51:30,515 --> 00:51:34,635
So they don't work well for alcohol
withdrawal and not something that

1007
00:51:34,635 --> 00:51:36,735
you're going to provide routinely.

1008
00:51:36,975 --> 00:51:39,075
Antipsychotics is another
one of these things.

1009
00:51:39,075 --> 00:51:42,945
It's kind of interesting because people
with schizophrenia can be alcoholics.

1010
00:51:42,945 --> 00:51:47,295
People who have hallucinations and are on
antipsychotics for multiple other reasons

1011
00:51:47,475 --> 00:51:49,335
can still go through alcohol withdrawal.

1012
00:51:49,335 --> 00:51:53,115
So you can give them antipsychotics
if you're treating things that are

1013
00:51:53,115 --> 00:51:56,265
not related to alcohol withdrawal
syndrome, and that's fine.

1014
00:51:56,325 --> 00:51:57,765
You can continue their medications.

1015
00:51:57,765 --> 00:52:02,835
But if they're having what looks like
psychosis, auditory, visual and tactile

1016
00:52:02,835 --> 00:52:06,495
hallucinations from alcohol withdrawal,
you're best off going down the alcohol

1017
00:52:06,495 --> 00:52:10,425
withdrawal syndrome pathway of benzos
and barbiturates and those medications.

1018
00:52:10,625 --> 00:52:13,085
And not administering
antipsychotics routinely

1019
00:52:13,684 --> 00:52:15,964
T.R. Eckler: The way I fall on this
is that you've gotta be worried about

1020
00:52:15,964 --> 00:52:17,374
respiratory depression in these patients.

1021
00:52:17,404 --> 00:52:20,854
'cause you're gonna give 'em a lot of
stuff and co administering antipsychotics

1022
00:52:20,854 --> 00:52:23,914
and benzos is gonna increase that
risk of respiratory depression.

1023
00:52:24,184 --> 00:52:28,054
But I also think there's always wisdom in
giving the patient their home medication.

1024
00:52:28,174 --> 00:52:31,054
And if the patient's on a long-term
antipsychotic and you know they're

1025
00:52:31,054 --> 00:52:34,054
on it and like, you know, you get 'em
a little stable and they're looking

1026
00:52:34,054 --> 00:52:36,964
okay, I think there is a place where
you give them their home medicine if

1027
00:52:36,964 --> 00:52:38,464
they're on a long-term antipsychotic.

1028
00:52:38,734 --> 00:52:40,774
But otherwise, I think you gotta
be real cautious with this.

1029
00:52:41,259 --> 00:52:42,159
Sam: Yeah, yeah.

1030
00:52:42,519 --> 00:52:42,939
Well said.

1031
00:52:43,639 --> 00:52:43,849
All right.

1032
00:52:43,849 --> 00:52:45,409
Let's talk about the intubated patients.

1033
00:52:45,409 --> 00:52:49,589
So this is the person who's already going
to the unit, and if you're listening and

1034
00:52:49,589 --> 00:52:53,669
you've never done one before, you can't
do a CIWA score or CIWA-AR on somebody

1035
00:52:53,669 --> 00:52:57,089
who's intubated because there are multiple
elements there that you can't answer

1036
00:52:57,089 --> 00:52:58,469
based on the patient being intubated.

1037
00:52:58,745 --> 00:53:01,365
And so the question comes
up, well, what can you use?

1038
00:53:01,365 --> 00:53:05,295
And the author suggests maybe the
Richmond agitation sedation scale

1039
00:53:05,295 --> 00:53:07,245
or the RASS can be more appropriate.

1040
00:53:07,245 --> 00:53:10,125
This is something we already use for
people who are intubated for multiple

1041
00:53:10,125 --> 00:53:12,675
other reasons to gauge sedation level.

1042
00:53:12,865 --> 00:53:17,195
It's there in table six on page 12, and it
includes things like are they combative?

1043
00:53:17,195 --> 00:53:19,175
Are they agitated, are they restless?

1044
00:53:19,275 --> 00:53:20,235
Are they alert and calm?

1045
00:53:20,235 --> 00:53:21,045
Are they drowsy?

1046
00:53:21,105 --> 00:53:22,485
Do they have light sedation, et cetera.

1047
00:53:22,485 --> 00:53:24,765
And it's a spectrum from
minus five to plus four.

1048
00:53:24,975 --> 00:53:28,815
And depending on where they are on the
spectrum, it can give you information

1049
00:53:28,815 --> 00:53:31,965
about whether or not you need to titrate
up or down your sedation medication.

1050
00:53:32,115 --> 00:53:35,955
So that's a possible alternative
for somebody who is intubated

1051
00:53:35,955 --> 00:53:37,035
in whom you need to see.

1052
00:53:37,155 --> 00:53:42,325
Okay, is my therapy effective enough to
reduce their alcohol withdrawal syndrome?

1053
00:53:43,025 --> 00:53:44,465
Patients with end stage liver disease.

1054
00:53:44,465 --> 00:53:48,905
We already mentioned about the sedation
effects and the extra lingering effects,

1055
00:53:48,905 --> 00:53:51,065
but just know that there is also a score.

1056
00:53:51,215 --> 00:53:54,815
You can score how far along on the
liver disease spectrum they are.

1057
00:53:54,815 --> 00:53:57,965
This is the MELD or the model
for end stage liver disease.

1058
00:53:58,145 --> 00:53:59,165
It's in MD calc.

1059
00:53:59,165 --> 00:54:01,955
I don't expect you to memorize it,
but it takes into account things

1060
00:54:01,955 --> 00:54:05,645
like their sodium, their INR, their
bilirubin and their creatinine, and

1061
00:54:05,645 --> 00:54:07,385
it predicts a three month mortality.

1062
00:54:07,575 --> 00:54:10,485
And the high scores can be
anywhere from six to 40.

1063
00:54:10,675 --> 00:54:13,255
And those are usually the people
who have more severe disease.

1064
00:54:13,255 --> 00:54:16,715
And that can be a poor prognostic
factor for multiple things.

1065
00:54:17,415 --> 00:54:18,735
And then the pregnant patients.

1066
00:54:18,735 --> 00:54:23,365
So the author is very upfront,
Hey, listen, benzodiazepines and

1067
00:54:23,365 --> 00:54:30,055
barbiturates have potentially teratogenic
effects, but the effects of alcohol

1068
00:54:30,055 --> 00:54:34,015
withdrawal on somebody who's pregnant
also come with high morbidity or

1069
00:54:34,015 --> 00:54:36,355
mortality for both mom and baby.

1070
00:54:36,565 --> 00:54:40,135
And so it's it's definitely a
line you have to ride, but just

1071
00:54:40,135 --> 00:54:43,225
know that a pregnant patient in
full blown alcohol withdrawal has

1072
00:54:43,225 --> 00:54:45,332
a high risk for this pregnancy.

1073
00:54:45,552 --> 00:54:47,422
And so you still have to treat it.

1074
00:54:47,452 --> 00:54:49,102
You still have to treat
it with these medications.

1075
00:54:49,262 --> 00:54:52,502
And if you don't treat it, you're
putting the patient at severe risk

1076
00:54:52,502 --> 00:54:56,012
for complications like abruption,
preterm delivery, and fetal distress.

1077
00:54:56,712 --> 00:54:58,897
T.R. Eckler: Make sure they're
not going into eclampsia and it's

1078
00:54:58,897 --> 00:55:00,007
not their alcohol withdrawal.

1079
00:55:00,037 --> 00:55:01,027
'cause it could be both.

1080
00:55:01,267 --> 00:55:05,017
So take a look at, you know, their urine
and their pressures and things like that.

1081
00:55:05,017 --> 00:55:07,597
And don't be afraid to give a
mag as well as benzos if you're

1082
00:55:07,597 --> 00:55:08,437
just kind of starting there.

1083
00:55:09,061 --> 00:55:09,301
Sam: Yep.

1084
00:55:09,511 --> 00:55:10,201
Yeah, absolutely.

1085
00:55:10,346 --> 00:55:12,411
that definitely gets to
be a complicated picture.

1086
00:55:13,111 --> 00:55:13,321
All right.

1087
00:55:13,321 --> 00:55:15,481
And let's talk about some kind
of cutting edge things, right?

1088
00:55:15,481 --> 00:55:18,781
So there are some alternative medications
that we like to use in the emergency

1089
00:55:18,781 --> 00:55:20,941
department, like ketamine, for example.

1090
00:55:21,091 --> 00:55:23,731
Ketamine has effects on the NMDA receptor.

1091
00:55:24,431 --> 00:55:25,841
We always love to talk about ketamine.

1092
00:55:25,841 --> 00:55:26,321
I mean, come on.

1093
00:55:26,691 --> 00:55:30,321
it has effects on the NMDA receptor,
which is already upregulated in

1094
00:55:30,321 --> 00:55:33,081
people who have chronic alcohol use.

1095
00:55:33,241 --> 00:55:34,561
So why not use it?

1096
00:55:34,591 --> 00:55:39,091
And honestly, there is, some evidence
mostly in the ICUs that suggests a

1097
00:55:39,225 --> 00:55:43,108
significant difference associated
with those receiving sub dissociative

1098
00:55:43,138 --> 00:55:47,473
ketamine infusions as an adjunct
for decreasing alcohol withdrawal

1099
00:55:47,653 --> 00:55:50,833
severity, especially if they're already
intubated and already on benzos.

1100
00:55:51,113 --> 00:55:54,713
So there is some evidence in the ICU,
there's not a big volume of literature

1101
00:55:54,773 --> 00:55:56,393
in the ED setting to support this.

1102
00:55:56,543 --> 00:55:59,063
So maybe not for the person
who has mild to moderate

1103
00:55:59,063 --> 00:56:00,233
withdrawal and is gonna go home.

1104
00:56:00,353 --> 00:56:03,113
But if they're already intubated
and you're already got them on some

1105
00:56:03,113 --> 00:56:06,593
kind of infusion and it's not quite
having the desired effect, you can

1106
00:56:06,593 --> 00:56:08,993
perhaps consider giving them ketamine.

1107
00:56:09,665 --> 00:56:12,635
T.R. Eckler: I fall in this one that
I like this for the intubated patient

1108
00:56:12,635 --> 00:56:14,705
that I'm having trouble controlling
their sedation even though I'm

1109
00:56:14,705 --> 00:56:17,795
going up on propofol, even though
I've given 'em a lot of benzos.

1110
00:56:18,015 --> 00:56:21,525
I think this is a nice third line agent
there to try to catch the intubated

1111
00:56:21,525 --> 00:56:24,495
patient and try to get them calmed
down before I get 'em up to the unit.

1112
00:56:24,495 --> 00:56:27,675
I think there's a role there and I also
think anytime you're intubated you gotta

1113
00:56:27,675 --> 00:56:29,175
make sure you're giving 'em pain control.

1114
00:56:29,325 --> 00:56:31,365
And I feel like they didn't kind
of talk about that, but you always

1115
00:56:31,365 --> 00:56:33,465
gotta make sure they're getting
something for pain as well.

1116
00:56:33,645 --> 00:56:35,295
'cause it's not comfortable
to be intubated.

1117
00:56:35,645 --> 00:56:39,846
I would say similarly to Naltrexone,
I think that there may be a role for

1118
00:56:39,846 --> 00:56:43,236
these in the emergency room at some
point, but I find that so often I'm

1119
00:56:43,236 --> 00:56:45,726
not quite sure where the patient
is on their withdrawal spectrum.

1120
00:56:45,876 --> 00:56:49,091
And I find that I would worry that I
would take someone that was good enough

1121
00:56:49,091 --> 00:56:52,121
to go home and all of a sudden make them
sick and not good enough to go home.

1122
00:56:52,301 --> 00:56:55,451
So I think that there's a great role for
these outpatient, but I'm not trying to

1123
00:56:55,451 --> 00:56:56,741
use 'em in the emergency room as much.

1124
00:56:56,951 --> 00:57:00,191
Whereas Gabapentin, I would tell you
may be the second biggest change in my

1125
00:57:00,191 --> 00:57:06,161
practice because I find that this is
much more well tolerated by patients.

1126
00:57:06,311 --> 00:57:09,701
I start 'em in the emergency room
with it, and I find that it seems more

1127
00:57:09,701 --> 00:57:14,291
successful than the Librium tapers I
had been giving before for patients.

1128
00:57:14,291 --> 00:57:17,531
And I think it's also less likely
to get abused than sending 'em

1129
00:57:17,531 --> 00:57:18,671
home with like a Valium taper.

1130
00:57:19,371 --> 00:57:19,821
Sam: Interesting.

1131
00:57:19,881 --> 00:57:22,851
You thinking about it as a
solo or as in addition to?

1132
00:57:23,346 --> 00:57:25,596
T.R. Eckler: I would tell you they
presented the article as in addition

1133
00:57:25,596 --> 00:57:30,126
to, but I'm using it often as a
solo thing and I'm finding lots of

1134
00:57:30,126 --> 00:57:34,326
success, especially in patients with
chronic pain issues or neuropathy.

1135
00:57:34,536 --> 00:57:36,366
You know, they're especially
ones that do well with it.

1136
00:57:36,516 --> 00:57:40,286
But really a lot of people, especially
the ones that you know, come in and

1137
00:57:40,286 --> 00:57:41,576
they're like, I really do want help.

1138
00:57:41,726 --> 00:57:44,276
I think this is a great drug for
that because I think they respond

1139
00:57:44,276 --> 00:57:47,156
really well to it and you can load
them in the emergency room with it.

1140
00:57:47,336 --> 00:57:50,606
I don't think I'm loading as high as
they recommend here at 1200 milligrams,

1141
00:57:50,756 --> 00:57:53,906
but I would tell you 300 to 600, I have
a lot of success and then I send 'em

1142
00:57:53,906 --> 00:57:56,816
home with a week's worth and really
kind of let 'em taper it themselves.

1143
00:57:56,966 --> 00:58:00,236
'cause I think that I try not to kind
of structure people as much anymore.

1144
00:58:00,236 --> 00:58:01,916
Like they have to do this over these days.

1145
00:58:01,916 --> 00:58:04,796
I just say, Hey, you're gonna try to wean
this down over the next week, and then

1146
00:58:04,796 --> 00:58:08,216
if you wanna stop drinking, you can do
that after the next week of using this.

1147
00:58:08,916 --> 00:58:09,116
Sam: Yeah.

1148
00:58:09,446 --> 00:58:09,746
Fair.

1149
00:58:10,121 --> 00:58:12,951
The, the article does mention
that there's not a whole lot

1150
00:58:12,951 --> 00:58:14,601
of evidence for gabapentin.

1151
00:58:14,601 --> 00:58:16,641
That doesn't mean it doesn't work,
but just we don't have a lot of

1152
00:58:16,641 --> 00:58:19,101
randomized placebo controlled
trials for this kind of thing.

1153
00:58:19,351 --> 00:58:21,541
There is some evidence that
there's a significant decrease in

1154
00:58:21,541 --> 00:58:25,171
length of stay and total amount
of benzodiazepine administration.

1155
00:58:25,421 --> 00:58:28,781
The author concluded there wasn't enough
evidence to support its use, but, you

1156
00:58:28,781 --> 00:58:32,171
know, given if there are confounding
variables or other indications for

1157
00:58:32,171 --> 00:58:35,471
its use, that it may be beneficial
in multiple indications at once.

1158
00:58:35,621 --> 00:58:38,531
So still more to come on that, but
it sounds like you've had some good

1159
00:58:38,531 --> 00:58:40,241
success with it, which is good to hear.

1160
00:58:40,821 --> 00:58:44,961
As another option dexmedetomidine
is something often used in the

1161
00:58:44,961 --> 00:58:49,131
ICU, and again, there hasn't
been much evidence around it.

1162
00:58:49,131 --> 00:58:52,491
There are some low quality
meta-analysis, which really didn't

1163
00:58:52,491 --> 00:58:55,911
demonstrate a significant difference
in the likelihood of intubation.

1164
00:58:56,096 --> 00:58:58,016
Or ICU length of stay.

1165
00:58:58,206 --> 00:59:02,016
But again, if they're already on
benzodiazepines and your intensivist

1166
00:59:02,016 --> 00:59:06,026
wants to use it as a adjunct then
by all means , there doesn't seem

1167
00:59:06,026 --> 00:59:07,316
like there's any harm to doing it.

1168
00:59:07,496 --> 00:59:10,376
Maybe there's not yet a volume
of evidence that shows benefit.

1169
00:59:10,886 --> 00:59:12,476
And then the last one was Baclofen.

1170
00:59:12,506 --> 00:59:14,636
It's interesting one, you
know, it does have effects on

1171
00:59:14,636 --> 00:59:16,766
gaba B receptor as an agonist.

1172
00:59:16,926 --> 00:59:20,226
In 2019 there was a Cochrane review
that found some low quality and

1173
00:59:20,226 --> 00:59:23,736
insufficient evidence for its efficacy
and safety in treating patients

1174
00:59:23,736 --> 00:59:25,086
with alcohol withdrawal syndrome.

1175
00:59:25,086 --> 00:59:28,176
So really, right now, there's no
recommendation to use this routinely.

1176
00:59:28,176 --> 00:59:29,826
There are just better options out there.

1177
00:59:30,306 --> 00:59:31,656
And lastly is disposition.

1178
00:59:31,656 --> 00:59:37,426
So again, it helps if you have a protocol
in your emergency department for the CIWA

1179
00:59:37,446 --> 00:59:41,766
score because then you can use some kind
of, you know, pseudo objective measure

1180
00:59:41,766 --> 00:59:45,396
to say, yes, they were appropriate to
go home, their CIWA was less than 10.

1181
00:59:45,666 --> 00:59:48,046
Or if you have an OBS unit,
you can say, oh, okay, their

1182
00:59:48,046 --> 00:59:49,986
CIWA's, whatever, less than 14.

1183
00:59:49,986 --> 00:59:52,816
And so we're gonna put them in the
obs unit and monitor them there.

1184
00:59:52,946 --> 00:59:56,216
So having those protocols set
ahead of time and using some kind

1185
00:59:56,216 --> 00:59:59,766
of objective criteria is helpful
to help you guide disposition.

1186
00:59:59,886 --> 01:00:02,016
Obviously, if they're sick enough
to go to the ICU, that's gonna be

1187
01:00:02,016 --> 01:00:05,436
pretty obvious and the CIWA scores
is not necessarily going to be

1188
01:00:05,436 --> 01:00:07,026
what is the primary driver for?

1189
01:00:07,726 --> 01:00:07,936
All right.

1190
01:00:07,936 --> 01:00:09,586
Five things that will
change your practice.

1191
01:00:09,586 --> 01:00:13,906
In summary, front loading and aggressive
early therapy for alcohol withdrawal

1192
01:00:13,906 --> 01:00:19,006
syndrome can prevent complications
and progression of symptoms for sure.

1193
01:00:19,696 --> 01:00:23,386
Benzodiazepines are still first-line
therapy, but phenobarb is showing

1194
01:00:23,386 --> 01:00:28,306
some promising results and both as
monotherapy and as an adjunct to

1195
01:00:28,306 --> 01:00:30,166
benzodiazepine can be quite helpful.

1196
01:00:30,866 --> 01:00:35,036
Third symptom-based treatment is more
effective than fixed scheduled treatment

1197
01:00:35,036 --> 01:00:36,266
for alcohol withdrawal syndrome.

1198
01:00:36,266 --> 01:00:39,986
We didn't actually mention this before,
but there are protocols for giving a

1199
01:00:39,986 --> 01:00:43,046
flat standard dose every set time period.

1200
01:00:43,051 --> 01:00:45,991
That's kind of a fixed
dose scenario or protocol.

1201
01:00:46,231 --> 01:00:49,171
And then there are those that are
symptom-based based on CIWA or

1202
01:00:49,171 --> 01:00:50,581
the patient's reported symptoms.

1203
01:00:50,911 --> 01:00:55,771
And there is evidence that if you use
a symptom-based protocol, you reduce

1204
01:00:55,771 --> 01:00:58,771
overall length of stay, patients report
better control of their symptoms.

1205
01:00:58,771 --> 01:01:01,291
And in general, it's just
more beneficial than just some

1206
01:01:01,291 --> 01:01:02,701
kind of fixed standard dose.

1207
01:01:02,701 --> 01:01:04,951
So tailoring it to your
patient is very helpful.

1208
01:01:05,651 --> 01:01:05,791
Fourth.

1209
01:01:06,191 --> 01:01:10,631
For carefully selected patients with mild
to moderate alcohol withdrawal symptoms

1210
01:01:10,721 --> 01:01:12,701
managed in the outpatient settings.

1211
01:01:12,921 --> 01:01:15,561
Gabapentin can be considered
as an alternative or as adjunct

1212
01:01:15,561 --> 01:01:17,481
to benzodiazepines, which
you already talked about.

1213
01:01:17,871 --> 01:01:19,881
And lastly, anti craving medications.

1214
01:01:19,881 --> 01:01:23,151
These are things like naltrexone,
acamprosate, and gabapentin should

1215
01:01:23,151 --> 01:01:26,391
be considered to prevent alcohol
relapse in eligible patients.

1216
01:01:26,391 --> 01:01:29,481
Of course, if you're already sending
them out on gabapentin, then hey, you're

1217
01:01:29,481 --> 01:01:31,031
getting two birds with one stone there.

1218
01:01:31,311 --> 01:01:34,821
So something to consider, especially if
you have a referral program and you know

1219
01:01:34,821 --> 01:01:37,551
you're gonna be sending them to follow up
with somebody and that's their protocol.

1220
01:01:37,551 --> 01:01:40,101
You could say, Hey, I'm sending you to
this place and this is what they use.

1221
01:01:40,101 --> 01:01:41,451
I'm just gonna start you on it now.

1222
01:01:41,671 --> 01:01:44,126
So it's helpful to know what
your community resources are.

1223
01:01:44,507 --> 01:01:47,667
T.R. Eckler: They did an RCT on
Gabapentin and found that the number

1224
01:01:47,667 --> 01:01:51,957
needed to treat was 5.4 for no heavy
drinking days, and the number needed

1225
01:01:51,957 --> 01:01:54,357
to treat for total abstinence was 6.2.

1226
01:01:54,597 --> 01:01:58,857
So you're looking at a number that's
getting pretty close to like Suboxone, you

1227
01:01:58,857 --> 01:02:00,567
know, for our opiate addicted patients.

1228
01:02:00,567 --> 01:02:04,107
So I think that this is the same kind
of approach you need, where the more

1229
01:02:04,107 --> 01:02:07,327
you offer up that opportunity for
them, the more often you're gonna

1230
01:02:07,327 --> 01:02:10,867
actually land some of these and get
some people to actually land in the

1231
01:02:10,867 --> 01:02:12,217
right spot and get the help they need.

1232
01:02:12,801 --> 01:02:15,921
Sam: Yeah, and if you're listening to
this podcast and you're thinking, gosh,

1233
01:02:15,921 --> 01:02:17,601
you guys talked about a ton of stuff.

1234
01:02:18,141 --> 01:02:21,861
How am I gonna put this all into
some kind of pathway or protocol?

1235
01:02:22,071 --> 01:02:26,241
Then hopefully you're a subscriber, and
if you're not, you should be, because

1236
01:02:26,241 --> 01:02:30,591
at the back of this article on page
23 is a fantastic clinical pathway.

1237
01:02:30,741 --> 01:02:33,171
It walks you through everything
we've just discussed.

1238
01:02:33,351 --> 01:02:37,291
It talks about using the CIWA and using
dosing based on where they are on the CIWA

1239
01:02:37,311 --> 01:02:39,541
score and then ultimately disposition.

1240
01:02:39,541 --> 01:02:42,541
And it walks you through
everything from assessment through

1241
01:02:42,721 --> 01:02:45,901
medication administration, and
then ultimately disposition.

1242
01:02:46,141 --> 01:02:47,821
Excellent, excellent pathway.

1243
01:02:47,821 --> 01:02:48,871
I highly recommend it.

1244
01:02:49,121 --> 01:02:52,871
And if you're not a subscriber, you should
be because you could then go and get your

1245
01:02:52,871 --> 01:02:56,261
four hours of CME credit for listening
to this podcast and reading this article.

1246
01:02:56,961 --> 01:03:01,611
And that brings us to the end of the
November, 2025 article in Emergency

1247
01:03:01,611 --> 01:03:03,561
Medicine Practice authored by Dr. Koo.

1248
01:03:03,621 --> 01:03:06,981
Thank you so much on the diagnosis
and management of alcohol

1249
01:03:06,981 --> 01:03:08,061
withdrawal symptom in the ED.

1250
01:03:08,421 --> 01:03:09,471
An excellent article.

1251
01:03:10,171 --> 01:03:10,531
T.R. Eckler: Great.

1252
01:03:10,621 --> 01:03:12,661
Give phenobarbital and Gabapentin a try.

1253
01:03:12,881 --> 01:03:13,841
It'll change your mind.

1254
01:03:14,231 --> 01:03:14,531
Sam: Yes.

1255
01:03:14,531 --> 01:03:17,381
Especially if you don't have
access to any other benzos, you

1256
01:03:17,381 --> 01:03:19,311
may not have a choice, right?

1257
01:03:19,341 --> 01:03:21,951
Necessity is the mother
of all invention, right?

1258
01:03:21,951 --> 01:03:22,851
Isn't that how the quote goes?

1259
01:03:22,851 --> 01:03:23,601
So here we go.

1260
01:03:24,301 --> 01:03:24,721
Awesome.

1261
01:03:24,781 --> 01:03:26,191
All right, everybody, thanks again.

1262
01:03:26,191 --> 01:03:27,001
Until next time.

1263
01:03:27,001 --> 01:03:27,991
I'm Sam Ashoo.

1264
01:03:28,421 --> 01:03:28,926
T.R. Eckler: TR Eckler.

1265
01:03:29,231 --> 01:03:32,381
Excited for another opportunity
next month hopefully.

1266
01:03:32,765 --> 01:03:33,990
Sam: Stay sober everyone.

1267
01:03:34,020 --> 01:03:34,780
See you in December.

1268
01:03:35,560 --> 01:03:37,380
And that's a wrap for
this month's episode.

1269
01:03:37,420 --> 01:03:40,000
I hope you found it
educational and informative.

1270
01:03:40,200 --> 01:03:45,060
Don't forget to go to ebmedicine.net
to read the article and claim your CME.

1271
01:03:45,230 --> 01:03:48,420
And of course, check out all three
of the journals and the multitude of

1272
01:03:48,420 --> 01:03:52,780
resources available to you, both for
emergency medicine, pediatric emergency

1273
01:03:52,780 --> 01:03:55,050
medicine, and evidence based urgent care.

1274
01:03:55,360 --> 01:03:57,330
Until next time, everyone be safe.