ERcast: Clinical Perspectives Podcast Preview
The summary below is from an episode of ERcast: Clinical Perspectives
Alcohol withdrawal syndrome is easy to undertreat and easy to make worse with inconsistent protocols. Diazepam remains a strong first-line benzodiazepine, and phenobarbital has a defined role in both early treatment and benzodiazepine-resistant withdrawal.
Phenobarbital in Alcohol Withdrawal
- Institutional treatment consistency: A single alcohol withdrawal assessment and treatment pathway reduces shift-to-shift variability, a common reason these patients deteriorate despite repeated ED care.
- Diazepam as first choice: Diazepam is a practical benzodiazepine anchor because it is bioequivalent PO, IM, and IV, and can be dosed in 10 mg aliquots for escalating withdrawal.
- Dual role for phenobarbital: Phenobarbital is not just a rescue drug; it can be used up front for admitted withdrawal patients and again when benzodiazepines are failing. We get into the selection nuances in the episode.
- Headline phenobarbital doses: Severe or benzodiazepine-resistant withdrawal is paired with 260 mg IV phenobarbital, while lower-risk admitted patients may start with oral loading followed by a taper.
- Cumulative dose awareness: Phenobarbital has a cumulative dosing phenomenon that may not declare itself in the ED, making total dose tracking and pharmacist involvement especially important.
- High-risk combination cautions: Use extra caution in older adults, and avoid stacking phenobarbital with both benzodiazepines and opioids because synergistic sedation can become the real emergency.
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- Bosch NA, et al. Implementation of a Phenobarbital-based Pathway for Severe Alcohol Withdrawal: A Mixed-Method Study. Ann Am Thorac Soc. 2021;18(10):1708-1716. PMID: 33945771
- Hammond DA, et al. Patient Outcomes Associated With Phenobarbital Use With or Without Benzodiazepines for Alcohol Withdrawal Syndrome: A Systematic Review. Hosp Pharm. 2017;52(9):607-616. PMID: 29276297
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- Rosenson J, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013;44(3):592-598.e2. PMID: 22999778
- Nejad S, et al. Phenobarbital for Acute Alcohol Withdrawal Management in Surgical Trauma Patients-A Retrospective Comparison Study. Psychosomatics. 2020;61(4):327-335. PMID: 32199629
- Ammar MA, et al. Phenobarbital Monotherapy for the Management of Alcohol Withdrawal Syndrome in Surgical-Trauma Patients. Ann Pharmacother. 2021;55(3):294-302. PMID: 32830517
Faculty
- Cameron Berg, MD
Based in Minneapolis, MN, Dr. Berg focuses on simplifying complex patient care processes, such as chest pain, syncope, and heart failure treatment. Since 2020, he has also been navigating his own recovery from a TBI after a bicycle accident. When he isn't in the clinic, Cameron is usually busy keeping his three young children alive and happy.
- Andy Little, DO
Dr. Andy Little is an emergency medicine physician and educator. He earned his medical degree from the Ohio University Heritage College of Osteopathic Medicine and completed his emergency medicine residency at OhioHealth Doctors Hospital Emergency Medicine Residency, where he served as Chief Resident. He has received multiple national awards, including recognition from the American Osteopathic Association, American College of Osteopathic Emergency Physicians, and Emergency Medicine Residents' Association.
