Over at the Pulmcrit blog, Dr. Josh Farkas has proposed the use of phenobarbital monotherapy for the treatment of ethanol withdrawal. He argues that phenobarbital has the following advantages:
- Superior neurochemistry
- Reliable – some patients will be resistant to benzos but this does not happen as much with phenobarbital
- Predictable pharmacokinetics
We cover alcohol withdrawal using Rosen’s Emergency Medicine (9th ed) Chapter 142 , Tintinalli’s Emergency Medicine (8th ed) Chapter 292, and Goldfrank’s Toxicologic Emergencies (10th ed) Chapter 81 as guides.
A 49-year-old man presents to the Emergency Department complaining of sweating and tremors. The patient drinks a bottle of liquor per day and stopped suddenly because of a pending court case. His last alcoholic drink was 3 days ago. On physical examination, his blood pressure is 168/105 mm Hg, pulse rate is 106/minute, respirations are 22/minute, and temperature is 99.3°F. The patient appears agitated and restless with a visible tremor of bilateral hands. The triage team ordered folic acid, thiamine, and a multivitamin. Which of the following is the most appropriate disposition?
A. Admit the patient and start diazepam
B.Admit the patient and start disulfiram
C.Discharge the patient with a prescription for diazepam
D.Discharge the patient with a prescription for disulfiram
Admit the patient and start disulfiram (A) is incorrect because the patient needs a benzodiazepine medication to prevent delirium tremens and potentially fatal consequences. Disulfiram is a medication used in some patients for long-term adherence to alcohol abstinence. Ingestion of alcohol while taking disulfiram causes copious vomiting and potentially more severe reactions. Discharge the patient with a prescription for diazepam (C) or disulfiram (D) is incorrect because alcohol withdrawal is potentially lethal and this patient should be admitted.
- “Alcohol Related Diseases.” Rosen’s Emergency Medicine. 9th ed. Chapter 142, 1838-1851.e1
- “Substance Use Disorders.” Tintinalli’s Emergency Medicine: A Comprehensive Review. 9th ed. Chapter 281.
- “Ethanol Withdrawal.” Goldfrank’s Toxicologic Emergencies. 10th ed. Chapter 81.
- Hendey GW, Dery RA, Barnes RL, Snowden B, Mentler P. A prospective, randomized, trial of phenobarbital versus benzodiazepines for acute alcohol withdrawal. Am J Emerg Med. 2011;29(4):382-385.
- Young GP, Rores C, Murphy C, Dailey RH. Intravenous phenobarbital for alcohol withdrawal and convulsions. Ann Emerg Med. 1987;16(8):847-850.