Alcohol Withdrawal

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the November 2025 Emergency Medicine Practice article, Diagnosis and Management of Emergency Department Patients With Alcohol Withdrawal Syndrome

1. Epidemiology & Background

• Rising ED visits related to alcohol use.
• Mortality rates and spectrum of patient presentations.
• Importance of high suspicion and complexity of cases.
• Pathophysiology & Mechanisms
• Alcohol metabolism and neurochemical changes.
• Differential diagnosis: Conditions that mimic alcohol withdrawal.
• Prehospital & EMS Considerations
• Role of EMS in triage and initial management.
• Use of sobering centers vs. ED transport.
• Prehospital administration of benzodiazepines (IM midazolam).
• History & Risk Assessment
• Key questions to assess risk for alcohol withdrawal syndrome.
• Importance of patient history, medication use, and comorbidities.
• Discussion on patient honesty and rapport.
• Physical Exam & Scoring Systems
• DSM-5 criteria for alcohol withdrawal.
• Use of CIWA-AR, BAWS, and PAWSS scoring systems.
• Importance of objective measurement for monitoring and disposition.
• Complications & Special Presentations
• Complicated alcohol withdrawal: Hallucinosis, seizures, delirium tremens.
• Diagnostic workup: Labs, imaging, and co-ingestions.
• Special populations: End-stage liver disease, pregnancy, intubated patients.
• Treatment Strategies
• Mainstay: Benzodiazepines (types, dosing, and protocols).
• Phenobarbital: Indications, dosing, and evidence.
• Adjunctive therapies: Thiamine, glucose, magnesium.
• Alternative/adjunct medications: Gabapentin, ketamine, dexmedetomidine, baclofen.
• Clinical Pearls & Practice Changes
• Early, aggressive therapy to prevent complications.
• Symptom-based vs. fixed-schedule treatment.
• Gabapentin as an alternative or adjunct.
• Anti-craving medications for relapse prevention.
• Disposition & Protocols
• Use of scoring systems for safe discharge, observation, or admission.
• Importance of protocolized approaches and community resources.
• Summary & Take-Home Points
• Five key practice-changing points.
• Clinical pathway.

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Episode Transcript

T.R. Eckler (2) (00:00):
it was one of those rare moments where the family, looks
at you and goes, what did you do?
And you say, ah, you know,had a thought, had a hunch.

Sam (2) (00:09):
Hi everyone, and welcome to another episode of EMplify.
I'm your host, Sam Ashoo.
Before we dive into this month's episode,I want to say happy Thanksgiving.
It is that time of year again,and with so much joy I say.
Thank you for being a subscriber.
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(00:31):
Get a free $50 Amazon gift cardfor spending $300 or more in the
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So many things to helpyou in your practice.

(00:52):
Go spend some money, get a giftcard, become a subscriber, and
have a wonderful Thanksgiving.
And now let's jump intothis month's episode.

Sam (01:03):
All ladies and gentlemen, welcome back to another episode of Emplify.
I am one of your hosts, Sam Ashoo,and on the other end of the microphone

T.R. Eckler (01:13):
Dr. TR Eckler, just like barbiturates.
I am back baby.

Sam (01:19):
here to talk about barbiturates only and why you should be using them,

T.R. Eckler (01:25):
Also gabapentin, that's really gonna be a theme for me today.

Sam (01:27):
Okay.
All right.
There you have it.
There's the summary.
Thanks for joining useverybody, and until next.
Oh wait, we're not done yet.

T.R. Eckler (01:33):
High yield quick hits.

Sam (01:35):
That's right.
That's super quick.
What are we talking about today?
We're talking about the emergencymedicine practice article from November,
2025, authored by Dr. Koo on thediagnosis and management of ED patients
with alcohol withdrawal syndrome.
A very timely article giventhe holidays coming up.

(01:55):
Many people seem to seek solace in alcoholinappropriately or maybe appropriately.
I don't know.
I don't know your families, but it'sdefinitely something we're going to see.
We see it here frequently inTallahassee, around weekends, Friday
nights, Saturday nights, footballweekends, homecoming college students.
And so this is a, a very timely topic andquite relevant to the emergency department

(02:19):
and once again, an outstanding article.
Some interesting introductory statistics.
I thought it was interesting to see thatthe data on alcohol intoxication and ED
visits shows that there's actually beenan increase steadily over the last decade
for ED visits related to alcohol use.

(02:40):
And mortality from alcohol withdrawalranges anywhere from one to 5%.
That's mortality.
So that's death we're talking about there.
And among heavy alcohol users admitted tothe hospital, that climbs a little higher,
just a kind of peeking around 7% or so.
So it's not a simple problem to fix.
And the spectrum of patientshere runs the gamut.

(03:02):
You got the people who are gonnago home and you got the people
who are gonna go to observation.
You got the people who have to beadmitted to inpatient, and then
you got the critically sick whoare going to the ICU and we're
gonna talk about all of them today.

T.R. Eckler (03:13):
this is not just kind of your alcoholic that shows up
disheveled on the EMS stretcher.
Like, you know, I've seen so manydifferent iterations of alcoholic
patients come in that I've justlearned to develop a really high
suspicion for this kind of thing.
I knew someone in medical school whosefather went in for like a normal surgery
and went into alcohol withdrawal anddied 'cause nobody really kind of

(03:34):
knew that he was drinking that much.
I've seen so many complications fromthe patient that seemed intoxicated
or delirious that actually also had ahead bleed or also had, co ingestion
or they had also overdosed on Tylenol.
And there's just so much complexityin pathology and this is just such
bread and butter, you know, reallychallenging emergency medicine, that

(03:55):
it's a great thing to really think hardabout every time you have one of these
patients as to how much you wanna work'em up and whether they're getting
better, whether you need to do more.

Sam (04:03):
Yeah.
Yeah, that's well said.
And even, you know, these patients,much like the patients we talked about
previously with adrenal insufficiency,these patients can present with alcohol
withdrawal as their primary diagnosis.
It can be a secondary diagnosis, it canbe because of some other thing going
on, and they can't drink alcohol, whichis what's thrown them into withdrawal.
And it can mimic sepsisand drug intoxication.

(04:25):
So this becomes a very pertinentdiagnosis and one that you have to
have a high suspicion for, for sure.
And I thought the author did a greatjob of of course finding an evidence
base for all the recommendations, butalso saying, Hey, you know, there is
kind of a, a paucity of good evidencebecause it's hard to get informed
consent for this population in general.
And there's a lack of a homogenouspopulation, meaning that there's

(04:49):
such a variety, like I mentionedbefore, from the people going home
to the people going to the ICU.
It's difficult to find somethingthat works in general for that
entire spectrum, and we end uptalking about things that work for
specific segments of this population.
If you're not aware, under typicalconditions, about 90% of your ingested
alcohol is absorbed within an hour.
It's a nice little tidbit there.

(05:10):
And another one is that absorptionoccurs starting in the gastrum or in the
stomach, and your gastric mucosa havealcohol dehydrogenase in them, which is
actually higher in males than in females.
Which therefore leads to ahigher bioavailability of
alcohol in females and males.
That's one of the reasons.
But also in your patients who've hadgastric bypass surgery will have less

(05:32):
alcohol dehydrogenase secretion inthe stomach to metabolize alcohol.
So there are small amounts of alcoholthat are excreted in the kidneys
and in the lungs and in the sweat.
But most of it is going to be metabolizedby the liver and eventually turned
into acetaldehyde and hopefullythen goes through that wonderful
kreb cycle that we all remember.

(05:54):
But the acetaldehyde, if it builds upenough, is what gives you that kind of
the hangover cluster of symptoms and theseverity of that is directly dependent to
the amount of alcohol that you consumed,because you can overwhelm that enzyme that
breaks down the alcohol and lead to a lotof this stuff building up in your system.
And so if you have someone who isalcohol intoxicated, your typical

(06:16):
metabolism is going to be about 20milligrams per deciliter per hour.
And if they're an experienced alcoholic,they can upregulate those enzymes and
metabolize, you know, anywhere from 25to 35 milligrams per deciliter per hour.
But it isn't gonna go anymuch faster than that.
So even in your chronic alcoholic who'sgot a sky high alcoholic level, you're

(06:36):
gonna be watching those people if they'reheavily intoxicated for a long, long time.
Which brings me to my firstquestion in trivia with TR.
Oh yeah, you forgot wedo that now, don't we?
Here we go.
This is uh, easy, easy, multiple choice.
Which of the following is a primarymechanism by which chronic alcohol use
alters neuro transmission in the brain?

(07:00):
All right, here we go.
Activation of the NMDAreceptor by alcohol.
Decreased GABAergic activity duringalcohol consumption, downregulation
of GABA receptors and upregulationof the NMDA receptors, inhibition
of the CYP two E one enzyme orstimulation of serotonin release.

(07:26):
So which of these is the primarymechanism by which chronic alcohol use
alters neuro transmission in the brain?

T.R. Eckler (07:31):
Gonna go with choice C.

Sam (07:33):
It is C, sir. Well done.
Downregulation of GABA A receptorsand upregulation of NMDA receptors
is actually the physiologic mechanismby which alcohol has its use.
And chronic use leads to an increasein both of those things, which means
you have a downregulation of yoursuppressive activity and an upregulation

(07:54):
of your NMDA excitatory receptorswhich is all great if you've got
alcohol in your system all the time.
But then when that alcohol'sgone, we have some problems.
And those problems lead tothe presentation in the ER.
and there is a great table as always, onpage five, discussing the differential
diagnosis of alcohol withdrawal, whichby the way is pretty broad, and that

(08:16):
is primarily due to the fact thatalcohol withdrawal symptom presents
with tachycardia, with hypertensionwith tremors and with multiple system
involvement and multiple vital signabnormalities, which you can get from
multiple other things like drug ingestionsfrom sympathomimetics, antimuscarinics,
sedative hypnotic withdrawal, severealcohol intoxication, interestingly,

(08:37):
will look like severe alcohol withdrawal.
And so sometimes it canbe difficult to tell.
And serotonin syndrome, allof those toxicologic diseases
should be in the differential.
And then you've got some othermedical things like thyrotoxicosis,
encephalitis, acute psychosis.
So if they're having activedelirium and visual hallucinations,
it can be hard, especially ifthere's a psychiatric history.

(08:59):
Hypoglycemia, head trauma,and sepsis and septic shock.
So lots of disease processes,especially pretty serious ones
that can mimic that presentation.
And things to keep in mind whenyou're suspecting someone has
alcohol withdrawal symptom.
And when we talk about our pre-hospitalcolleagues and what they can do
there was a pretty good section here.

(09:20):
I really enjoyed reading the descriptionof all of the things that our
pre-hospital colleagues are already doing.
So one of the biggest thing is rapidtransport to an appropriate facility.
And when discussing that, the authorwas quick to point out that about 40%
of all ED visits for alcohol relatedcomplaints arrive by ambulance.
So, you know, a bulk of the populationis coming by EMS and that the

(09:43):
presence of markedly abnormal vitalsigns or severe agitation prompts
pre-hospital personnel to transportthe patient to a medical facility
rather than a psychiatric facility.
Because in many areas we havesobering centers or places where
EMS can take somebody to sober up ifthey're thought to just be alcohol

(10:03):
intoxicated which are wonderful.
There's good evidence behind thosefacilities that they are appropriate
and that they can reduce ED utilization.
In fact, the data suggests therewas a 2019 review and found only
4% of patients got transferredfrom sobering centers to the ED.
So that means 96% of the timewe're getting that decision right.

(10:24):
So that's a very importantdistinction that our pre-hospital
colleagues have to make.
And when they figure out, Hey, thisperson needs to go to the medical
side, then there is some therapythey can initiate on the way to the
hospital, specifically benzodiazepines,depending on what they're carrying.
So IM midazolam, collecting informationabout possible ingestion or co ingestions

(10:44):
or drug utilization from the patientor from other people who are on the
scene trying to see if they see obviousevidence for drug paraphernalia there.
All of these things become very, veryimportant and then measuring that mental
status and how it changes over time.
So depending on how long the transportis, they can get a little bit of time with
the patient and trend their mental status.

(11:06):
And so by the time they get to the ED, ifthey're floridly confused but didn't start
that way, that can be an important clue.
So lots of things that our EMSpersonnel can do to help us in not
only gathering information, but helpingdecipher exactly where they should go.
Whether that's a sobering center or an ED,

T.R. Eckler (11:23):
Have you ever worked somewhere that had a sobering center?

Sam (11:25):
I kind of thought that one of the pods in our emergency department
was the sobering center for a while.

T.R. Eckler (11:30):
I think having just worked Halloween where we did reopen
one of the pods to become a soberingcenter, I would tell you that
that's not an inaccurate assessment.
But when I was in Denver Health doing myaway rotation in medical school, they had
one of these for Denver Health, and itwas such a refreshing thing to be like,
wait, you can just send the intoxicatedpatients that look pretty good somewhere.
And they were like, yeah, youcan just send them all out.

(11:51):
Like they just go over to the soberingcenter and then a couple will come
back, but most of 'em are fine.
And it was just such a great way todecompress your ER, especially at
like those peak evening kind of times.
It was a well thought out andhighly effective intervention
from what I remember.

Sam (12:04):
Now, in that area, they went to the Sobering center from the ED.
So they came to the ED first, andthen you decided if they could go.

T.R. Eckler (12:10):
And, or they could go straight there.
It kind of depended on who brought 'emin and things like that, but it was an
option from the ER to move them to there.
And I, I thought it was just oneof those neat ways to kind of
help you move through the volume.
So it was a positive experience.
And then I just wanted tohighlight how much I appreciate.
I think IM midazolam is just sucha great choice for these patients
in the prehospital setting.
'cause I think that giving longeracting benzos sometimes to these

(12:33):
patients will kind of cloud thepicture for a longer period of time.
Whereas I really like when I get ashort term control from EMS and then
they come in and I can kind of get asense in the first hour or two as to
where they're going as opposed to like,that starts to sneak by me and then
it's a couple hours later and maybethey're getting admitted for something
and then stuff starts to wear off.
So I always really like whenpre-hospital people can give more
short acting things if they can.

Sam (12:53):
Yes, yes, absolutely.
And I'm sure the pre-hospitalpeople like it as well.
IM Midazolam is a great drug, workssuper fast intramuscularly and as you
said, is short acting, kind of theideal agent for pre-hospital setting.
And then when they get to the EDand it's time to obtain our history,
assuming we can get it from the patient.
Table two on page six is a greatsummary of the kinds of things that we

(13:14):
want to know when we're interviewingsomebody to decide if they have risk
factors for alcohol withdrawal syndrome.
Like have they personally hadalcohol withdrawal syndrome before?
That's probably the mostimportant question to ask.
But also, is there a family history of it?
Do they have any known metabolicderangements, liver problems, cirrhosis?

(13:35):
Do they have a history ofthrombocytopenia that kind of
goes hand in hand with cirrhosis?
Also important to ask whentheir last drink was, how
much did they normally drink?
Have they ever had withdrawals inthe past, and how severe were they?
Did they result in an ICU admission?
Did they have true delirium tremens?
Did they have visual andauditory hallucinations?
Have they ever had withdrawal seizures?

(13:55):
All those are very, verypertinent questions to ask.
And if for some reason you're able toelicit that they have stopped drinking
or cut back on their drinking, youreally have to follow it up with a
question about why that's the case.
If they want to stop drinking, that'sfantastic, but if you forgot to ask
why, and it turns out they have severeepigastric abdominal pain and acute

(14:17):
pancreatitis, and that's why theystopped drinking, that's an important
piece of information to elicit as well.

T.R. Eckler (14:23):
This is such a patient population that I just
have more questions always
When I try to teach students aboutthis, I'm like, you know, 1% of the
time they've just decided it's time andthey've decided to stop drinking the
other 99% of the time, there's some otherreason and you really wanna know that.
'cause it might be pancreatitis,it might be a GI bleed.
It might be because they started reallygoing into DTs and they realized that

(14:45):
things were getting worse or theygot into something else like a toxic
alcohol or they overdosed or somethingelse has happened that has interrupted
their normal pattern of behavior.
And you need to have just the highestlevel of suspicion 'cause these are
people that are not doing something thatis respected and they're going to always
be trying to hide it and minimize it.

(15:05):
So the more that you can develop thatrapport with them and try to really like
establish the trust and try to establishas much that you're there to help them.
And then gradually build towhere you ask about their use
and you ask about their history.
And I think something that I learnedtoo is how much more common the tactile
hallucinations are than the visual ones.
I'm not asking enough about if youfeel something like that, because

(15:26):
I feel like everyone's got wormsand bugs in the ER these days.
But I think this is something whereI'm gonna try to tease that more
delicately from these patients tosee if I can catch earlier which ones
are actually heading for DTs and needto be looking at like an ICU stay.

Sam (15:40):
And, you know, I always found that my patients fell into two categories.
Those who were completely in denial orwere still trying to hide it from people.
And so they were minimizing how muchthey drink and those who were just
completely open about everything, Icould just say, how much do you drink?
They would be completely upfront.
And I'd say, have you everhad procedures before?
Oh yeah, I've had three andI've been at ICU once and I've
been to detox a hundred times.
And then I would always follow it up with,you know, do you want to go back today?

(16:02):
Is today the day?
And sometimes people would justsay, no, no, I'm gonna go right
back and start drinking again.
I go, okay, so we'renot seeking detox today.
Like, nope, no, not at all.
And sometimes people would say yes, youknow, I've been there a hundred times.
Today's gonna be 101.
I'm hoping it's gonnabe the time that sticks.
And that's important to differentiate.
So don't be afraid to just beblunt and ask those questions.
It doesn't have to be accusatory.

(16:23):
Just 'cause you're asking.

T.R. Eckler (16:24):
I also think that this is also more of a history
piece than more of an exam piece.
So I wanna move this forward in thediscussion, but I think it's important
to ask about other medicationsthey're using, because I find that
in other populations I'm more worriedabout, are you taking propanolol?
Are you taking labetalol or metoprolol?
Are you taking something that's gonna,you know, like slow down your heart rate?
And these are patients that are, becausetheir alcohol abuse are gonna be more

(16:47):
prone to AFib, they're gonna be moreprone to having other medical problems.
And if they're taking a beta blockeror if they're taking clonidine or
tizanidine or guanfacine that's gonnablunt their withdrawal symptoms and the
appearance of their withdrawal and kindof dampen the things that are gonna make
you think that they're getting worse.
So that was something that I took awayfrom this, that I needed to be more
cautious of, to make sure that this wasn'tsomeone that I was hiding their symptoms

(17:11):
by having other medicines in their tank.

Sam (17:13):
yeah, yeah, exactly.
We're not, covering up alcohol withdrawalbecause we forgot to ask about medications
that might blunt some of those symptoms.
Alright.
Couple more questions.
Which of the following statementsabout Sobering Centers is accurate?
So they provide long-term detox programs.
They are appropriate forpatients with severe withdrawal.
They manage medical complicationsof alcohol withdrawal.

(17:37):
They typically monitor vitalsigns and offer referrals.
And they require inpatientadmission orders?

T.R. Eckler (17:44):
It's D. I love them for that.

Sam (17:47):
That's right.
That's right.
They do a great job.
They're monitoring vital signs.
So yes, they're doing that and they'reoffering referrals and they're there
literally just to keep someone untilthey're sober enough to go home.
They're not there to treat alcoholwithdrawal, but they do provide
a good service and they do offerreferrals to patients for sure.
All right, one more question.
What is the most predictiverisk factor for developing

(18:07):
alcohol withdrawal syndrome?
So when they're there in the ED and we'retrying to figure out, okay, what's your
risk for alcohol withdrawal syndrome?
What's the most predictive risk factor?
A blood alcohol level on arrivalgreater than one 50 B, a history
of alcohol withdrawal seizures,C, low serum potassium, D male
sex, or E use of antidepressants.

T.R. Eckler (18:30):
My experience on Halloween suggests that male sex
is concerningly close to the truth.
But I think that this is, ifyou've previously had alcohol
withdrawal and seizures, thatis the most predictive factor.
I

Sam (18:42):
Yeah.

T.R. Eckler (18:43):
Found that the discussion in the article about kindling that
basically the more you feed the fire,the harder it is to get it under
control was very apt for these patients.
And I, I really did think it characterizedsome of these people that they're really
kind of burning through themselvesand drinking harder and harder.
And you need to be aware thatthey're gonna need more and
more benzos to control 'em.
So you need to be ready toescalate and get more aggressive.

(19:04):
'cause they come in months laterand they may be significantly
more ill than they were before.

Sam (19:09):
Yeah.
Yeah.
You brought up a great point there to thispoint about kindling, meaning that the
more times that someone cycles througha severe alcohol withdrawal and then
medical treatment and then goes back todrinking and then comes back again in
alcohol withdrawal, this cycle actuallymakes it more difficult in subsequent
episodes to treat their acute alcoholwithdrawal and they end up needing

(19:30):
escalating doses of benzodiazepines.
So if you have an EMR that allows you tolook back at prior admissions and see what
they used last time, that's not enough tojudge what they're gonna need this time.
Just know that it's a very goodpossibility they'll need more this
admission than they did during theprevious admission, especially if there
have been multiple prior admissions.

(19:50):
So that was a great point in the article.
And also 'cause I like figures and tables.
Figure one in the article on page six foralcohol withdrawal syndrome, the timeline,
which I thought was very helpful.
You've got the green timeline, whichis six to 12 hours where they're just
symptomatic headache, anxiety, maybesome nausea and vomiting and some
abdominal pain, palpitations and tremors.

(20:13):
And then once you get past 12hours, that 12 to 36 hour range has
worsening tachycardia, increasingblood pressure, maybe seizures,
maybe agitation, maybe fever.
And then finally the worst case inthe red zone, 36 hours to a week where
they get the true disorientation,the altered mental status, the

(20:34):
hallucinations and the delirium tremons.
So kind of three buckets to putyour patient in depending on
when their last drink occurred.
and kind of helps gauge who you think isgoing to be able to go where, depending
on how far on the spectrum they are.

T.R. Eckler (20:48):
don't put too much faith into the answer as to when exactly their
last drink was, because much like the lasttime you used opiates, I'm not sure that
they're regularly going to defer to givingyou the honest truth in these cases.

Sam (21:00):
Yeah.
Not to mention the fact that, youknow, in order to tell you when their
last drink was, you have to know whattime it is now and what day it is.

T.R. Eckler (21:07):
Or what time it was then

Sam (21:08):
Exactly.

T.R. Eckler (21:10):
Because you might have passed out

Sam (21:10):
Exactly.

T.R. Eckler (21:13):
It's not something that I put a lot of faith in.
I'd say, okay, alright, we'llkind of see how it goes.

Sam (21:17):
Fair enough, fair enough.
When it comes to physicalexamination, there are some things
you're gonna be looking for.
Tremor, nausea, vomiting, hallucinations,psychomotor agitation, anxiety,
seizures, and autonomic hyperactivity.
Those are all the DSM five TR criteria.
And that's not TR as inTR Eckler, by the way.

(21:37):
That's TR as in text revision.
So.

T.R. Eckler (21:39):
Do you feel like I've seen enough of these patients to
have a scoring scale of my own?

Sam (21:42):
You might, you might.

T.R. Eckler (21:44):
I was alarmed though that the DSM five said that you only
need two of the eight to qualifybecause that seemed just about as
broad as usually is with these people.
All alcoholics can kind of fitinto the withdrawal picture
if they try hard enough.

Sam (21:57):
Yes, yes, yes.
That makes it very, verylikely that they're gonna fall
into that bucket for sure.
Now that doesn't tell youwhere they are on the spectrum.
That just tells you that they haveenough elements to get the diagnosis,
alcohol withdrawal syndrome, andthen there is a good discussion
there about scoring the severity.
So this is interesting.
I actually had a recent debatewith some emergency physicians

(22:18):
about this particular issue.
When we talk about the CIWA-AR, so thisis the Clinical Institute Withdrawal
Assessment of Alcohol Scale revised.
So that's the CIWA-AR,or Alcohol Scale Revised.
And it's a questionnaire.
It's got several questions on here,just asking about everything from
nausea and vomiting and tremors andsweats to anxiety and agitation.

(22:41):
And then the disturbances,tactile disturbances, auditory
disturbances, visual disturbancesheadache, and then orientation.
And some of these are objective, someof these are very subjective 'cause
you're asking them or you're justkind of interpreting them yourself.
And depending on where they score,they can be mild, moderate, or severe.
So less than 10 is mild, 10 to18 is moderate, and more than

(23:03):
19 or 19 or more is severe.
And that becomes helpfulfor a number of reasons.
Now, the debate I had with theemergency physicians we were
talking to was, who does this?
And whether or not this is required,it's obviously not required to make the
diagnosis of alcohol withdrawal syndrome.
You don't have to have a specificallyhigh or low CIWA to make the diagnosis.

(23:26):
But it is helpful for monitoringthe progression of their symptoms or
hopefully the improvement of theirsymptoms, their response to therapy.
And for anybody you're gonna hand off thepatient to, so if you're gonna admit them
to the inpatient wards or the OBS unit,one of your colleagues, or the ICU, it's

(23:46):
important for them to know where thisperson started, where they are now, and if
they're improving with what you've done.
And there has to be some kindof objective measure for that.
And honestly, a lot of times ournursing colleagues are the ones
who get stuck having to do this.
And this can be done, you know, onceevery hour, once every four hours.
It just depends on how sick theperson is and what your protocol is.

(24:07):
But it's helpful to havesomething documented.
And also as is always the case, whenthere is something documented, it
ends up getting kind of eaten up byour coding and billing colleagues.
And so many insurance companies willuse an initial CIWA score to justify
an OBS versus an inpatient payment.
And so even though it may be somethingyour nursing colleague did and you

(24:31):
documented something far worse, ifyour nursing colleague documents a very
minor CIWA score, this person may endup just reimbursing at an OBS level.
And so it does have some repercussions butit is also clinically helpful, especially
if you're gonna trend ongoing therapy.

T.R. Eckler (24:47):
I think, not to jump the gun, but I think that there's value
here when you're looking more atgiving longer acting, you know, less
exhilarating benzos, or when you lookat a drug like phenobarbital, because
I think that patients are gonna bemore likely to give you an honest
assessment if they know there's not amountain of Valium coming their way.
So I think that there's more valuehere if you can get kind of a gradual

(25:11):
control of the patient's symptoms withsomething that's longer acting and less
of a euphoric high kind of creating.
Did you look at any of the otherscoring systems they have out
there now like they suggested here.

Sam (2) (25:20):
Yeah, there is two others that the author mentioned, The BAWS
or the Brief Alcohol WithdrawalScale and the PAWSS or prediction of
Alcohol Withdrawal Severity Scale,all three of which are on MD Calc.

T.R. Eckler (25:31):
I thought BAWS and CIWA both had the potential for, if you were the
patient and you wanted to really enhanceyour symptoms, everything could be a 10
outta 10 or a seven outta seven I guess.
'cause most of them are scored outta that.
But I really liked the PAWSS 'causeI think that it's a good way of
saying, Hmm, you know, this is thealcoholic patient I got, what's
my level of concern about them?
Do I think they need ICUor step down or the floor?

(25:53):
I thought this was a cool tool that Ithink is gonna help me land patients more
appropriately in the right level of care.
'cause I think it's gonna tease outsome of the higher risk patients
that I don't think I'm necessarilyasking all the right questions to.

Sam (26:05):
If you're concerned or want to see what a CIWA looks
like, it's there on page eight.
There are a number of resourcesonline where you can just download
this form and print it or put it ina digital form and incorporate it in
your EMR if it's not already there.
It's probably the one that is themost widely studied and has the
biggest body of evidence behindit, and that's the CIWA-AR.
The others like you mentioned alreadythere are some in MD calc, the SEWS or the

(26:28):
SEWS severity of ethanol withdrawal scaleis not on MD calc, but the other two are.
There's not as much evidencefor those in the ED, but that
doesn't mean they're not helpful.
Just pick one, have somethingthat is consistently used.
It is more helpful for everyone touse the same one than it is for you
to use one and for your inpatientcolleague to use a different one.
So there may have to be some compromisethere, but the point is having some

(26:51):
kind of objective or pseudo objectivemeasuring scale is helpful because it
helps guide your therapy especially ifyou're gonna be doing symptom management
based dosing as opposed to just aset schedule dosing for medications,
which we'll get into in a second.

T.R. Eckler (27:06):
I would also just add, I think that it's tricky to
really assess hand fasciculations.
I think that sometimes it'sconvincing, but sometimes patients
are trying to either enhance itor they're trying to cover it up.
They're trying to kindof do one or the other.
I find tongue fasciculations tobe a lot more reliable 'cause
it's a pretty hard thing to do.
And I'll often askpatients to do it together.
I'll be like, hold out yourhands and stick out your tongue.

(27:27):
And they're used to it being hands, sothey won't think about their tongue.
And I find that that gives me a kindof cleaner indication of how ill
they are and how I'm doing in termsof controlling their withdrawal.

Sam (27:37):
Yeah, great points.
There is an entity called ComplicatedAlcohol Withdrawal, and that's really just
as things are progressing and your alcoholwithdrawal now encompasses hallucinations
or seizures and you're being diagnosedwith delirium or delirium tremons, those
are encompassed by the global diagnosisof complicated alcohol withdrawal.

(27:58):
And then there is alcohol withdrawal.
Hallucinosis which again iskind of, we're just working
our way up to delirium tremons.
So this is hallucinations,visual, auditory, or tactile.
More frequently tactile, less frequently,auditory and even less frequently visual.
And this is anywhere from one to 12%of patients, depending on how sick
the population is, you're admitting.

(28:18):
But they get this altered sensoriumand this eventually progresses to
full-blown delirium tremons if untreated.
And then there is alcohol withdrawalseizures, which we've talked about
on the podcast before when wetalked about status epilepticus.
It's a pretty rare complication, less than3% but it can occur and the treatment here
is always benzodiazepines and not reallythe standard anti-epileptic medications.

(28:41):
They don't tend to do a goodjob in this kind of scenario.
Patients with alcohol use disorder are atincreased risk for lots of CNS conditions.
So this is the rub, includinginfections, subdural hematomas, metabolic
derangement, and drug ingestion.
And so even though they're coming inseizing with a history of alcohol use,

(29:01):
it can be difficult to say for surethis is alcohol withdrawal until you've
excluded all of those other things.
Just keep that in mind.

T.R. Eckler (29:08):
I think the caution is when you are having trouble controlling them.
So you've given a couple rounds ofbenzos and they're still having seizures.
I've had patients like thisthat now it's trauma, now it's a
subarachnoid, now it's a poisoning.
Now it's hypoglycemia.
So you need to keep kindof moving the gears.
'cause EMS will come in andsay, ah, this is an alcoholic.
We know him.
He gets seizures.
And you've gotta keep that high levelof suspicion that you know, they're

(29:31):
sicker than they usually are, orthere's a problem I can't control.
So it's gotta be something else.
So I find that the CT scannerand more labs and more workup
is your best friend here.
So keep following your gut.

Sam (29:42):
All right, and on that note, another question.
A 52-year-old man is brought to theED altered diaphoretic, grasping
at the air he was last seen fourdays ago for alcohol intoxication,
what is the most likely diagnosis?
Is it alcohol intoxication?
Alcohol withdrawal, hallucinosis?

(30:03):
Is it delirium tremons?
Is it schizophrenia or is itWernicke's Encephalopathy?

T.R. Eckler (30:10):
I tell you that he could be just hallucinosis or it could be
heading towards delirium tremons.
I would start with hallucinations, butI would have a high index of suspicion
that we were heading there too.

Sam (30:22):
Yeah, so you're correct.
The answer, the technical answer isdelirium tremons, but delirium tremons
your manifestation is gonna be delayed.
So he was last seen four daysago for alcohol intoxication.
If he hasn't had a drink since then,it takes about 72 hours to push
you into that red zone where you'rein full blown delirium tremons.
Your hallucinations are gonna start rightaround 36 hours and so he is somewhere

(30:44):
on the verge of delirium tremons.
But yes, I will take alcohol withdrawalhallucinosis because right at 36
hours is when that's gonna begin.
And either one of those could becomplicating this presentation.
And on that note, let's talk aboutdiagnostic studies, specifically labs.
So this isn't gonna be amajor surprise to anyone.

(31:04):
We order a bunch of labs in the ED.
So you're gonna get yourroutine labs, so your CBC your
chemistry, your renal function.
It is helpful to get coagulationstudies if you know they have a
history of cirrhosis or if they looklike they're cirrhotic because that
can help you gauge how far alongin their liver disease they are.
You should expect to seethings like thrombocytopenia

(31:25):
and anemia and leukopenia.
So, low white blood cell count, lowhemoglobin, low platelet count in your
chronic alcoholics is pretty common.
You can actually get an elevated whiteblood cell count from things like alcohol
withdrawal seizures but just know there'sa lot of overlap here with other diseases,
so you can't rely on that for anything.

(31:47):
But there are some things that are common.
An alcohol level is also helpful,especially if there's any question
about whether or not the person'sintoxicated versus in true withdrawal.
There are chronic alcoholics whowill begin to withdraw long before
their alcohol level reaches zero.
So we've all seen those people, we knowthem well, and that's treated clinically.

(32:07):
So don't be afraid to begin the benzosearly or if they're gonna go home, you
know, discharge them as soon as they'reclinically sober so that they don't
withdraw in your emergency department.
And then testing for co-ingestions.
So aspirin, Tylenol a drug screen,which you know, is universally not
great, but better than nothing cansometimes tell you if there's some
sympathomimetics on board, some cocaine,some amphetamines, anything else that

(32:28):
might be altering their vital signs.
So all of that is helpful.
An EKG is very helpful especiallyif they have severe electrolyte
deficiencies to take a look at theirQT intervals, because things that
are seizures or things that look likeseizures may not always be seizures.
And so you can get arrhythmiasthat's pretty common.
Atrial fibrillation probablybeing one of the most common.

(32:48):
And then there's imaging.
So chest x-ray is indicatedif there's hypoxia or fever or
any kind of chest discomfort.
CT imaging of the brain is certainlyindicated if they have alterations
in their mental status or seizuresor evidence of head trauma.
And so those are probablypretty routine for most of us
in the emergency department.

T.R. Eckler (33:07):
Any suspicion for trauma?
I would say I'm adding a CT of theircervical spine to that as well, because
I've seen plenty of those kind of traumaswhere they've got multiple injuries.
And then I think this articleconvinced me I need to be thinking
more about an ammonia level.
I think that more of these, youknow, sicker, older alcoholics, I
need to be aware that their livercan be failing and there can be some
degree of hepatic encephalopathy.

(33:29):
So I think that's something tohelp my colleagues upstairs as
to give them a starting point asto where their ammonia level is.

Sam (33:35):
Yeah, for sure.
Point of care glucose is another one.
You know, we mentioned hypoglycemia butthey can get alcohol ketoacidosis and get
pretty significant acidosis and you'regonna give 'em fluids and then you're
gonna give them IV D 10 or infusionsof some kind of glucose solution.
And you wanna give them the thiamine.
And so when we get into the meds, we'lltalk about all of that, but just know
that those are pretty common derangements.

(33:56):
We're gonna see hypo mag.
If there's not a magnesium includedin your chemistry profile, you're
gonna want a magnesium level.
So it's not a sparing approach totesting for this patient population.

T.R. Eckler (34:07):
I really try to look at their anion gap because if there's
really a metabolic acidosis there andit's significant, and I don't think
it's because of lactic or I don't thinkit's because of alcoholic ketoacidosis,
then is there a toxic alcohol there?
And I think this is a group that I'malways trying to catch, like did they
get into something else while they weredrinking and is there something else I
need to be worried about that they mightneed, you know, dialysis for or something

(34:28):
to clear because the earlier you get tothat answer, the better it's gonna be.
So I try to keep that high index ofsuspicion for, we're looking at labs
for these patients to really kindof see what it looks like and then
considering further workup or talkingto poison control if I've got concerns.

Sam (34:42):
All right, let's get into treatment.
So we talked already about thatkindling effect, where repeated cycles
of withdrawal and intoxication kindaheightened their CNS hyperexcitability
and cause longer duration andseverity of withdrawal symptoms.
And so they may need escalatingdoses of medications.
So be alert to the fact that thismay not be their first presentation.

(35:03):
the really mainstay of treatment hereis decreasing overall stimulation.
'cause this is what the alcohol wasdoing before it went away, and this is
what their brain has been accustomed to.
And the mainstay for doingthat is still benzodiazepines.
And we'll talk more about otheroptions here in just a second.
But the benzodiazepines are well studied.

(35:24):
There's a good volume of evidence behindthem, especially in this population.
Not necessarily specific to one agent.
It started back in the1960s with chlordiazepoxide.
This is oral Librium therapy.
And so there's a large volume ofevidence behind that particular therapy.

T.R. Eckler (35:41):
OG Baby.

Sam (35:42):
Yeah.

T.R. Eckler (35:42):
Nobody ever asks for a refill on Librium.
It works and it isn't awesome.

Sam (35:47):
It, it does very well.
The other benzodiazepines in thiscategory include things like diazepam,
which is rather long acting witha half-life of 20 to 80 hours.
Lorazepam, which is muchshorter acting 10 to 20 hours.
Midazolam, which is the shortestacting, that's six hours.
And then chlordiazepoxide,which is anywhere from 24 to
84 hours, but is oral only.

(36:08):
And so those four benzodiazepines makeup the bulk of therapy, and there are
multiple ways to go about doing this.
I like that the author recommended apretty liberal approach to medicating
patients, especially as they first startto develop symptoms, kind of getting on
top of them early, not having to waituntil they're in full blown withdrawal

(36:29):
because then you're catching up andsomebody who might have even been able
to go home is now stuck maybe havingto go inpatient or even to the ICU.
So it is important to recognizeit and recognize it early.
Nowadays in the era of medicationshortage, you may not have the
luxury of deciding between theseagents, and so just know that the

(36:50):
chlordiazepoxide is oral only.
So that leaves you with onlythree IV options, midazolam,
lorazepam, and diazepam.
And if given the option betweenthe three diazepam is the longest
acting, but also has some hepaticmetabolism that has to be occurred in
order to clear it from your system.
So if you've got somebody who'scirrhotic, it's gonna be on board for

(37:12):
a little longer maybe than you intend.
Lorazepam does not undergothe same hepatic metabolism.
It only undergoes the phasetwo hepatic metabolism.
So it's gonna be eliminatedmostly by the kidneys and it
may be more reliable for dosing.
Midazolam works great for IM,if you don't have an IV yet, and
we've already mentioned that.
So there are some nuances to medications,but by and large it's gonna be,

(37:34):
you know, what do you have and whatdo you have in large quantities?
Because depending on how sick they are,these patients can take anywhere from like
triple digits to four digit milligrams.
We're talking about grams ofmedication to get symptomatic control.
And over the course of daysin the ICU, they run through
massive quantities of medication.

(37:54):
And so when it comes to benzodiazepines,it's going to be give it, give it
early be liberal, but know thatyes, there are some side effects.
You know, sedation probably beingthe one people worry about the most.
But it's not a reason towithhold therapy by any means.

T.R. Eckler (38:10):
I would say the state in our shop right now is such that we only
have versed, we have very, very limited,if not non-existent supplies of Valium
and Ativan or diazepam and Lorazepam.
So essentially we're, you know, givingMidazolam when it's indicated, but then
we're moving to oral or other strategieslike our next topic of Gabapentin because

(38:33):
there's just such a need to preserveour benzo supply of what we can to have
it not just for these patients, butfor our patients with agitated delirium
or other patients that need sedationor for our pediatric seizure patients.

Sam (38:44):
Yeah, great point.
And there are some shops that haveconverted to phenobarbital exclusively.
It's just their first levelmedication that they're giving
initially, and they're not evendiscussing benzodiazepines anymore.
And we'll get into that in two seconds.
First, a trivia question, inwhich situation is Lorazepam
preferred over diazepam fortreatment of alcohol withdrawal?
In patients with mild withdrawal symptoms,in patients requiring IM medication, in

(39:08):
patients with end stage liver disease,in patients with a history of epilepsy,
or in patients with hypotension.

T.R. Eckler (39:15):
C you don't want to give it to the cirrhotics.

Sam (39:18):
That's right.
That's right.
Only because lorazepam, like I saidbefore only has phase two liver metabolism
while diazepam does have to go throughthe full liver metabolism and it can
hang around a lot longer than intended.
Again, if that's all you have,don't withhold it because of that.
But if you have the luxury of choosingbetween the two and you know the
person has end stage liver disease,you're headed for the Lorazepam.

(39:41):
All right, let's dive into phenobarbital.
So phenobarbital has been aroundfor a very long time and it is a
medication that was used for alcoholwithdrawal, then was kind of dropped
and we went to benzodiazepines andnow it's kind of making a resurgence.
It's in the category of medicationscalled barbiturates and it has a distinct
binding site on that GABA A receptor.

(40:02):
And it increases chloride influx.
And I don't wanna get too deepinto the physiology of it,
but just know that it works.
But it works by a secondary mechanism,so it has a different pathway
than your typical benzodiazepine.
And it can result in symptomaticcontrol for much longer periods,
we're talking like half lifeof 120 hours, and the tapering

(40:24):
effect from a single loading dose.
And so you can get more or less whatsome people have described, ideal
alcohol withdrawal coverage that lastsmultiple days and then gradually tapers
off without having to give somebodya prescription for a Librium or give
them multiple doses of benzodiazepines.
You can just load them once andthen as soon as they're clinically

(40:44):
sober, discharge them home.
And many centers have converted tothat as being their first line therapy.
You use much phenobarbital?

T.R. Eckler (40:52):
This is the biggest change in my practice in the last five years.
I would tell you that because ofshortages and because of just the
severity of some of the patients thatwe've seen and the fact that now I'm
not transferring them out, they'restaying in my shop compared with like my
rural times where a lot of times thesepatients would be getting transferred.
I am giving a lot more phenobarbital,both for patients getting admitted

(41:13):
and patients that are gettingdischarged because as you said, I
think it gives me guaranteed control.
It really stabilizes the patientin a really reliable way.
And it doesn't preclude you then fromgiving other medication on top of
that, whether that's a little morephenobarbital or benzos or something else.
But it's gonna decrease thetotal amount you're gonna need of

(41:33):
anything else by a dramatic amount.
And I think that, especially whenI'm, you know, admitting to a very
busy hospital, the hospital's full.
I'm worried when the inpatientteam is gonna get to some of
the patients or this or that.
I find that taking control of thesesituations is with the phenobarbital
load in the emergency room, especiallygiven that we have great ER pharmacists
that help us to administer it it'sa great tool to have and it has

(41:55):
completely from when I was in residencyand in the rural places to now I've
completely gone a 180 on it because Iused to say, ah, no, I'm a Valium guy.
I'm from New York City.
That's what we do, and now I really havestarted to lead with this more and more.
I find it especially really helpful inthe kind of patient that's, you know,
not sick from alcohol, but sick fromsomething else, like say an aspiration

(42:15):
pneumonia or COVID or flu, and they'rea little hypoxic and they look unwell.
Giving them a loading dose ofphenobarbital often stabilizes them in a
way that gives them a chance to like cooloff and calm down without you constantly
debating of, should I give this patientbenzos when they need oxygen already?
I'm worried about theoxygen demand getting worse.
It gives you a chance to treat oneproblem and then move on and focus

(42:38):
on the next one, and then if theyget worse, you know that it's because
that's what you need to work on.

Sam (42:43):
Yeah, that's perfectly said right there.
there is some evidencebehind phenobarbital.
There's very little comparing head tohead phenobarb versus benzodiazepine.
So there was one study citedby the author a prospective
randomized trial, 44 patients.
So very small comparing lorazepam tophenobarb and it showed no difference in
the mild to moderate alcohol withdrawalsyndrome as far as admission rates.

(43:04):
Follow up CIWA scores at48 hours from discharge.
That at least is one comparison study.
There's lots of clinical anecdotes.
There was one meta-analysis of 12studies, so that's a total combined
population of almost 2000 patientsthat compared benzos to phenobarbital
and showed there was no differencesin the rate of intubation, seizures,

(43:27):
hospitalization, and ICU length of stay.
But also there are now somedouble-blinded, randomized placebo
controlled trials that compare benzosonly to benzos plus phenobarbital.
And found that those treated withphenobarbital had significantly lower
rates of ICU admission compared toplacebo, but also highlighting that if

(43:49):
they had phenobarb plus benzodiazepines,they fared better than just benzos alone.
So it is now something that is beingrecommended as a reasonable alternative
by a lot of clinical practice guidelines.
The ASAM, A-S-A-M, the GRACE fourtrial and recommendations, and
the Society for Academic EmergencyMedicine, all of them are recommending

(44:09):
these as potential alternativetherapies or adjuncts to first line.
So you can certainly replace them ifyou're comfortable or if that's become
the standard protocol in your shop.
Great.
Just make sure that you have some kindof protocolized approach and that you
know, everybody's on the same page.
That yes, this is what we're doing.
The loading dose is 10 milligrams perkilo IV given over about 30 minutes,

T.R. Eckler (44:30):
That's ideal body weight though.
You gotta make sure you're basing itoff their ideal body weight because not
everyone is at their ideal body weight.

Sam (2) (44:37):
I have no idea what you're talking about, sir. Yes,
thank you for that correction.
10 milligrams per kilo of idealbody weight, or you can give 260
milligrams IV over five minutesfor moderate symptoms, just as a
one time non-weight based dosing.
And then subsequent dosingcan occur every 30 minutes as
needed until you get symptomaticrelief up to a gram in 24 hours.

(44:59):
So you can get pretty high doses.
And the most important thingto remember is that this is a
kind of a one and done thing.
Once you get them loaded andthey've achieved control they're
good for up to 120 hours.
So you know, if they have appropriatecontrol of symptoms, normal vital
signs are awake and alert and aren'treally sedated by this medication.
This is somebody who could go home.

(45:19):
Somebody who you would've previouslygiven a prescription to for Librium
and said, this is how I want youto taper over the next few days.
This kind of is on automatic taperas they metabolize it, and they
don't have to worry about it anymore.
The patient does have to be reliable.
You know, they're supposed to not goand drink alcohol during this time
period, just like they would if itwas Librium or some other benzo.
So you do have to selectyour patient appropriately.

(45:42):
And know that the typical side effectsfor phenobarb are pretty much the same
things you're gonna get from benzos.
We're talking respiratorydepression and over sedation.
It does have kind of a narrow therapeuticwindow, which means there's a little
more rapid progression from, you know,normal to sedated as you're giving it.
But once you get used to it and you'vebecome someone who uses it more frequently

(46:03):
you'll get comfortable with that dosing.
And a protocolized approachis really the best way to go.

T.R. Eckler (2) (46:08):
10 milligrams Per kilogram ideal body weight over 30
minutes is what we're using in our shop,and I've had tons of success with it.
I find that sometimes then afterwards, ifthe patient's still a little anxious, I'll
give them a little bit of Valium as well.
'cause sometimes I thinkthey think they need it.
But I think once you let this reallykick in, the patients do great.
I think my one caveat for these patientsis you don't wanna use this in that
really sick, really altered, you know,delirium, tremons patient if you really

(46:32):
think they're heading for the ICU, becauseI think that those kind of patients you
might wanna consider propofol, precedex,something that's a little more short
acting that you can adjust more carefully.
And I've gotten support forthat from my ICU colleagues.
I think that kind ofvaries from shop to shop.
So I think that's worth a discussionbetween the ER and the, you
know, medicine and the ICU teams.
But I think that that's an area that we'restill trying to work out kind of exactly

(46:55):
which patients do best with phenobarbitalversus precedex versus propofol and benzos
and kind of what the right mixture isfor the really, really sick patients.

Sam (47:05):
Yeah.
Yeah, that's another great point.
If they're already headed to the ICUand you're not trying to just prevent
that, then certainly a conversationwith your intensivists about what
their preferences are is due inadvance of the patient presentation.
There are some adjunctive therapies.
So we mentioned thiamine.
All of these patients are going to be,you know vitamin deficient and are gonna
need thiamine, and most of them are gonnaend up on some kind of glucose solution.

(47:28):
The ideal timing is togive the thiamine first.
But if they're hypoglycemic, you'renot gonna withhold the glucose in
order to give them the thymine first.
You could certainly start it and thengive the thiamine and it's okay to
give them simultaneously as well.
So they're definitely gonnabe thiamine deficient.
The standard dose is a hundredmilligrams IV, but if they have
symptoms like nystagmus or ataxiaor confusion, those are the symptoms

(47:51):
of Wernicke's encephalopathy.
Most people will havenot all three of these.
So you know, only 10% of the populationwho actually has Wernicke's encephalopathy
will show all three of these.
But that's kind of the, the textbooktriad nystagmus, ataxia and confusion.
If they are already presenting withthose, then you're talking about larger
doses, like 500 milligrams IV of thiamine.

(48:12):
But the standard dose is a hundredIV and you give it hopefully before
you start your dextrose solution

T.R. Eckler (2) (48:17):
I've had one round of high dose thiamine basically
cure a patient right on the spot,like over the course of an hour.
A man came in, just bumbling andreally just in a rough state.
And he'd been like that for a fewdays and his wife just said, well,
I thought he was gonna get better.
And I was like, you know, Ireally think this is Wernicke's.
And I gave him 500 of thiamine andover the course of an hour or two, he

(48:37):
came around and was his normal selfagain and talking and everything else.
And I was pretty excited to get himadmitted for a couple of days of thiamine
and making sure he didn't progress.
But it was one of those raremoments where the family, looks
at you and goes, what did you do?
And you say, ah, you know,had a thought, had a hunch.

Sam (48:54):
House MD. That's right.
TR Eckler.
Well done, sir. Well done.
And then the author does talk aboutlike we mentioned before kind of this
risk-based strategy for potentiallyloading someone in advance of symptoms.
So someone you know is going to withdraw.
You know that they're going to be therelonger than they want to be, you know

(49:15):
that they're gonna start withdrawing.
There is benefit shown to starting thatbenzodiazepine therapy early opposed
to waiting until they're in withdrawal.
So you can then not have to play catchup.

T.R. Eckler (49:26):
Have a brief moment of we need to modernize something for the
modern age, the cage questionnaire.
I remember being taught about the cagequestionnaire in medical school and
I thought it was the judgiest worstquestionnaire I had ever encountered.
And I stand by that 20 years laterthat this thing needs to be changed.
I think we need to sit down and come upwith something that's got a better name.

(49:49):
You can't call it the cage.
That sounds like a trap.
'cause it's a trap you gotta come upwith something that makes it cool.
It's like that Saturday Night Liveskit they did where they was like, you
know, interviewing guys on a podcast ishow they do their medical visits now.
Like that's what I think we need issome kind of thing where it's like,
hey, do you like to party great?
How much do you like to party?
Do you need to like, havesomething to drink after you've
had a big night of partying?

(50:10):
We gotta work on the way thatquestionnaire works to make it
not seem so much like it's a trap.

Sam (50:15):
Yeah.
Yeah, that's fair.

T.R. Eckler (50:16):
I stand in opposition to the cage questionnaire.

Sam (50:19):
If you're listening, CAGE stands for cut, annoyed, guilty and eyeopener.
And it's a questionnaire that's meantto kinda gauge where they are on their
propensity for alcohol withdrawalbecause it can affect you know, your
suspicion for alcohol withdrawal ordeveloping alcohol withdrawal syndrome.
And there actually is pretty decentevidence behind the questionnaire and

(50:42):
how early administration of lorazepamin high risk patients on the cage
questionnaire can decrease length of stay.
So it is a helpful questionnaire,but I agree with you.
The acronym does sounda little sanctimonious

T.R. Eckler (50:54):
There's PAWSS.
I like, 'cause I'm just trying tosee how much of an animal you are.
Like maybe you got some big paws.
That's okay.
I'm just trying to make sure that Itake the best care of you as I can.
That's what I'm here for.

Sam (51:04):
right.
On that note, let's move onto anti-seizure medication.
All I gotta say aboutthat is just don't do it.

T.R. Eckler (51:12):
No,

Sam (51:13):
It doesn't work.
It does not work.

T.R. Eckler (51:14):
Unless they have head bleed, then we can talk about it.

Sam (51:17):
Okay, then you're gonna treat their alcohol withdrawal and they're probably
gonna get dual coverage from that anyway.
But anti-seizure medications uniformlyfail when compared with benzodiazepines.
That's a direct quote from the article andpretty much all we need to say about that.
So they don't work well for alcoholwithdrawal and not something that
you're going to provide routinely.
Antipsychotics is anotherone of these things.

(51:39):
It's kind of interesting because peoplewith schizophrenia can be alcoholics.
People who have hallucinations and are onantipsychotics for multiple other reasons
can still go through alcohol withdrawal.
So you can give them antipsychoticsif you're treating things that are
not related to alcohol withdrawalsyndrome, and that's fine.
You can continue their medications.
But if they're having what looks likepsychosis, auditory, visual and tactile

(52:02):
hallucinations from alcohol withdrawal,you're best off going down the alcohol
withdrawal syndrome pathway of benzosand barbiturates and those medications.
And not administeringantipsychotics routinely

T.R. Eckler (52:13):
The way I fall on this is that you've gotta be worried about
respiratory depression in these patients.
'cause you're gonna give 'em a lot ofstuff and co administering antipsychotics
and benzos is gonna increase thatrisk of respiratory depression.
But I also think there's always wisdom ingiving the patient their home medication.
And if the patient's on a long-termantipsychotic and you know they're
on it and like, you know, you get 'ema little stable and they're looking

(52:34):
okay, I think there is a place whereyou give them their home medicine if
they're on a long-term antipsychotic.
But otherwise, I think you gottabe real cautious with this.

Sam (52:41):
Yeah, yeah.
Well said.
All right.
Let's talk about the intubated patients.
So this is the person who's already goingto the unit, and if you're listening and
you've never done one before, you can'tdo a CIWA score or CIWA-AR on somebody
who's intubated because there are multipleelements there that you can't answer
based on the patient being intubated.
And so the question comesup, well, what can you use?

(53:01):
And the author suggests maybe theRichmond agitation sedation scale
or the RASS can be more appropriate.
This is something we already use forpeople who are intubated for multiple
other reasons to gauge sedation level.
It's there in table six on page 12, and itincludes things like are they combative?
Are they agitated, are they restless?
Are they alert and calm?
Are they drowsy?
Do they have light sedation, et cetera.

(53:22):
And it's a spectrum fromminus five to plus four.
And depending on where they are on thespectrum, it can give you information
about whether or not you need to titrateup or down your sedation medication.
So that's a possible alternativefor somebody who is intubated
in whom you need to see.
Okay, is my therapy effective enough toreduce their alcohol withdrawal syndrome?

(53:43):
Patients with end stage liver disease.
We already mentioned about the sedationeffects and the extra lingering effects,
but just know that there is also a score.
You can score how far along on theliver disease spectrum they are.
This is the MELD or the modelfor end stage liver disease.
It's in MD calc.
I don't expect you to memorize it,but it takes into account things
like their sodium, their INR, theirbilirubin and their creatinine, and

(54:05):
it predicts a three month mortality.
And the high scores can beanywhere from six to 40.
And those are usually the peoplewho have more severe disease.
And that can be a poor prognosticfactor for multiple things.
And then the pregnant patients.
So the author is very upfront,Hey, listen, benzodiazepines and
barbiturates have potentially teratogeniceffects, but the effects of alcohol

(54:30):
withdrawal on somebody who's pregnantalso come with high morbidity or
mortality for both mom and baby.
And so it's it's definitely aline you have to ride, but just
know that a pregnant patient infull blown alcohol withdrawal has
a high risk for this pregnancy.
And so you still have to treat it.
You still have to treatit with these medications.
And if you don't treat it, you'reputting the patient at severe risk

(54:52):
for complications like abruption,preterm delivery, and fetal distress.

T.R. Eckler (54:56):
Make sure they're not going into eclampsia and it's
not their alcohol withdrawal.
'cause it could be both.
So take a look at, you know, their urineand their pressures and things like that.
And don't be afraid to give amag as well as benzos if you're
just kind of starting there.

Sam (55:09):
Yep.
Yeah, absolutely.
that definitely gets tobe a complicated picture.
All right.
And let's talk about some kindof cutting edge things, right?
So there are some alternative medicationsthat we like to use in the emergency
department, like ketamine, for example.
Ketamine has effects on the NMDA receptor.
We always love to talk about ketamine.
I mean, come on.
it has effects on the NMDA receptor,which is already upregulated in

(55:30):
people who have chronic alcohol use.
So why not use it?
And honestly, there is, some evidencemostly in the ICUs that suggests a
significant difference associatedwith those receiving sub dissociative
ketamine infusions as an adjunctfor decreasing alcohol withdrawal
severity, especially if they're alreadyintubated and already on benzos.

(55:51):
So there is some evidence in the ICU,there's not a big volume of literature
in the ED setting to support this.
So maybe not for the personwho has mild to moderate
withdrawal and is gonna go home.
But if they're already intubatedand you're already got them on some
kind of infusion and it's not quitehaving the desired effect, you can
perhaps consider giving them ketamine.

T.R. Eckler (56:09):
I fall in this one that I like this for the intubated patient
that I'm having trouble controllingtheir sedation even though I'm
going up on propofol, even thoughI've given 'em a lot of benzos.
I think this is a nice third line agentthere to try to catch the intubated
patient and try to get them calmeddown before I get 'em up to the unit.
I think there's a role there and I alsothink anytime you're intubated you gotta
make sure you're giving 'em pain control.
And I feel like they didn't kindof talk about that, but you always

(56:31):
gotta make sure they're gettingsomething for pain as well.
'cause it's not comfortableto be intubated.
I would say similarly to Naltrexone,I think that there may be a role for
these in the emergency room at somepoint, but I find that so often I'm
not quite sure where the patientis on their withdrawal spectrum.
And I find that I would worry that Iwould take someone that was good enough
to go home and all of a sudden make themsick and not good enough to go home.

(56:52):
So I think that there's a great role forthese outpatient, but I'm not trying to
use 'em in the emergency room as much.
Whereas Gabapentin, I would tell youmay be the second biggest change in my
practice because I find that this ismuch more well tolerated by patients.
I start 'em in the emergency roomwith it, and I find that it seems more
successful than the Librium tapers Ihad been giving before for patients.

(57:14):
And I think it's also less likelyto get abused than sending 'em
home with like a Valium taper.

Sam (57:19):
Interesting.
You thinking about it as asolo or as in addition to?

T.R. Eckler (57:23):
I would tell you they presented the article as in addition
to, but I'm using it often as asolo thing and I'm finding lots of
success, especially in patients withchronic pain issues or neuropathy.
You know, they're especiallyones that do well with it.
But really a lot of people, especiallythe ones that you know, come in and
they're like, I really do want help.
I think this is a great drug forthat because I think they respond

(57:44):
really well to it and you can loadthem in the emergency room with it.
I don't think I'm loading as high asthey recommend here at 1200 milligrams,
but I would tell you 300 to 600, I havea lot of success and then I send 'em
home with a week's worth and reallykind of let 'em taper it themselves.
'cause I think that I try not to kindof structure people as much anymore.
Like they have to do this over these days.
I just say, Hey, you're gonna try to weanthis down over the next week, and then

(58:04):
if you wanna stop drinking, you can dothat after the next week of using this.

Sam (58:08):
Yeah.
Fair.
The, the article does mentionthat there's not a whole lot
of evidence for gabapentin.
That doesn't mean it doesn't work,but just we don't have a lot of
randomized placebo controlledtrials for this kind of thing.
There is some evidence thatthere's a significant decrease in
length of stay and total amountof benzodiazepine administration.
The author concluded there wasn't enoughevidence to support its use, but, you
know, given if there are confoundingvariables or other indications for

(58:32):
its use, that it may be beneficialin multiple indications at once.
So still more to come on that, butit sounds like you've had some good
success with it, which is good to hear.
As another option dexmedetomidineis something often used in the
ICU, and again, there hasn'tbeen much evidence around it.
There are some low qualitymeta-analysis, which really didn't

(58:52):
demonstrate a significant differencein the likelihood of intubation.
Or ICU length of stay.
But again, if they're already onbenzodiazepines and your intensivist
wants to use it as a adjunct thenby all means , there doesn't seem
like there's any harm to doing it.
Maybe there's not yet a volumeof evidence that shows benefit.
And then the last one was Baclofen.

(59:12):
It's interesting one, youknow, it does have effects on
gaba B receptor as an agonist.
In 2019 there was a Cochrane reviewthat found some low quality and
insufficient evidence for its efficacyand safety in treating patients
with alcohol withdrawal syndrome.
So really, right now, there's norecommendation to use this routinely.
There are just better options out there.
And lastly is disposition.
So again, it helps if you have a protocolin your emergency department for the CIWA

(59:37):
score because then you can use some kindof, you know, pseudo objective measure
to say, yes, they were appropriate togo home, their CIWA was less than 10.
Or if you have an OBS unit,you can say, oh, okay, their
CIWA's, whatever, less than 14.
And so we're gonna put them in theobs unit and monitor them there.
So having those protocols setahead of time and using some kind
of objective criteria is helpfulto help you guide disposition.

(59:59):
Obviously, if they're sick enoughto go to the ICU, that's gonna be
pretty obvious and the CIWA scoresis not necessarily going to be
what is the primary driver for?
All right.
Five things that willchange your practice.
In summary, front loading and aggressiveearly therapy for alcohol withdrawal
syndrome can prevent complicationsand progression of symptoms for sure.
Benzodiazepines are still first-linetherapy, but phenobarb is showing

(01:00:23):
some promising results and both asmonotherapy and as an adjunct to
benzodiazepine can be quite helpful.
Third symptom-based treatment is moreeffective than fixed scheduled treatment
for alcohol withdrawal syndrome.
We didn't actually mention this before,but there are protocols for giving a
flat standard dose every set time period.
That's kind of a fixeddose scenario or protocol.

(01:00:46):
And then there are those that aresymptom-based based on CIWA or
the patient's reported symptoms.
And there is evidence that if you usea symptom-based protocol, you reduce
overall length of stay, patients reportbetter control of their symptoms.
And in general, it's justmore beneficial than just some
kind of fixed standard dose.
So tailoring it to yourpatient is very helpful.
Fourth.
For carefully selected patients with mildto moderate alcohol withdrawal symptoms

(01:01:10):
managed in the outpatient settings.
Gabapentin can be consideredas an alternative or as adjunct
to benzodiazepines, whichyou already talked about.
And lastly, anti craving medications.
These are things like naltrexone,acamprosate, and gabapentin should
be considered to prevent alcoholrelapse in eligible patients.
Of course, if you're already sendingthem out on gabapentin, then hey, you're
getting two birds with one stone there.

(01:01:31):
So something to consider, especially ifyou have a referral program and you know
you're gonna be sending them to follow upwith somebody and that's their protocol.
You could say, Hey, I'm sending you tothis place and this is what they use.
I'm just gonna start you on it now.
So it's helpful to know whatyour community resources are.

T.R. Eckler (01:01:44):
They did an RCT on Gabapentin and found that the number
needed to treat was 5.4 for no heavydrinking days, and the number needed
to treat for total abstinence was 6.2.
So you're looking at a number that'sgetting pretty close to like Suboxone, you
know, for our opiate addicted patients.
So I think that this is the same kindof approach you need, where the more
you offer up that opportunity forthem, the more often you're gonna

(01:02:07):
actually land some of these and getsome people to actually land in the
right spot and get the help they need.

Sam (01:02:12):
Yeah, and if you're listening to this podcast and you're thinking, gosh,
you guys talked about a ton of stuff.
How am I gonna put this all intosome kind of pathway or protocol?
Then hopefully you're a subscriber, andif you're not, you should be, because
at the back of this article on page23 is a fantastic clinical pathway.
It walks you through everythingwe've just discussed.

(01:02:33):
It talks about using the CIWA and usingdosing based on where they are on the CIWA
score and then ultimately disposition.
And it walks you througheverything from assessment through
medication administration, andthen ultimately disposition.
Excellent, excellent pathway.
I highly recommend it.
And if you're not a subscriber, you shouldbe because you could then go and get your
four hours of CME credit for listeningto this podcast and reading this article.

(01:02:56):
And that brings us to the end of theNovember, 2025 article in Emergency
Medicine Practice authored by Dr. Koo.
Thank you so much on the diagnosisand management of alcohol
withdrawal symptom in the ED.
An excellent article.

T.R. Eckler (01:03:10):
Great.
Give phenobarbital and Gabapentin a try.
It'll change your mind.

Sam (01:03:14):
Yes.
Especially if you don't haveaccess to any other benzos, you
may not have a choice, right?
Necessity is the motherof all invention, right?
Isn't that how the quote goes?
So here we go.
Awesome.
All right, everybody, thanks again.
Until next time.
I'm Sam Ashoo.

T.R. Eckler (01:03:28):
TR Eckler.
Excited for another opportunitynext month hopefully.

Sam (01:03:32):
Stay sober everyone.
See you in December.
And that's a wrap forthis month's episode.
I hope you found iteducational and informative.
Don't forget to go to ebmedicine.netto read the article and claim your CME.
And of course, check out all threeof the journals and the multitude of
resources available to you, both foremergency medicine, pediatric emergency

(01:03:52):
medicine, and evidence based urgent care.
Until next time, everyone be safe.