Alcohol Withdrawal
Alcohol Withdrawal
Uncomplicated Alcohol Withdrawal
Serum Ethanol Level < 300
Treated with Long Acting Gaba Agonist in the main ED
Phenobarbitol Preferred
5 mg / kg for mild withdrawal
10 mg / kg for moderate or worse
Marked improvement in Symptoms with initial treatment in the ED
Patient desiring alcohol cessation
No significant electrolyte abnormalities
Patient is ambulatory
Recent admissions (last 6 months) complicated by severe alcohol withdrawal including seizures, ICU or Delirium Tremens
Seizure or hallucinations present on this visit.
More than 20 mg / kg of phenobarbital needed for initial control in main ED
New Atrial Fibrillation or other arrhythmia
Unable to ambulate
Serum Alcohol > 300 (will take > 24 hours for full spectrum of withdrawal to present)
Significant sedation with GABA agonists in ED
Cardiac monitoring
End Tidal Capnometry
SEWS Monitoring Q2h
IF SEWS is greater than 0 but less than 7
Phenobarbitol 5 mg / kg
IF SEWS is greater than 7
Phenobarbitol 10 mg / kg
Vitamin Supplementation
Folic Acid 1 mg Now and daily
Thiamine 500 mg IV Q24
Multi-Vitamin Now and daily
Gastritis Prevention
Pantoprazole 40 mg PO on admission and daily
Famotidine 20 mg Q12 h PRN
TUMS / Maalox PRN
GABA Adjunct Therapy
Gabapentin 900 mg on evening of admission followed by 600 mg 12 hours later
Alcoholism Treatment
Start Oral Naltrexone 50 mg daily (unless on long term oral opiate therapy)
BHE Visit (not full eval) for Resources and outpatient treatment referral
Disposition
SEWS < 1 on three serial measurements
Patient able to ambulate and care for self safely in home environment
Taking normal PO food and able to take PO medications
Stable vital signs
Discharge on Oral Naltrexone 50 mg daily. If treated with phenobarbitol, no further GABA agonist medications should be needed
SEWS remains > 7 on three measurements (despite 2 treatments with phenobarbitol between measurements)
Development of seizure, hallucinations or altered mental status
Over-sedation
Arrhythmia or persistent tachycardia > 130 despite treatment
Fever, Hypotension or other abnormal vital sign
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