Alcohol Withdrawal - Phenobarbital Protocol - For moderate-severe withdrawal
IM load+PO taper. Binds GABA-A and glutamate, t1/2 = 1-4d.
NO MORE BENZOS after phenobarb started
Side Effects: apnea, hypoventilation, hypotension, bradycardia, laryngeal spasm
To calculate doses:
Input: 1) Height (IBW) 2) High-risk withdrawal?: Past DTs +/- sz AND [EtOH use in <2wks OR active w/d sx OR +BAL with labs predictive of severe w/d (low plts, high MCV, low K)] 3) High-risk sedation?: age>65, liver dz, head injury, recent benzos, concurrent sedatives
*If cirrhosis: slower excretion/metabolism, max load 8mg/kg, check level and adjust taper. Stop taper after 2d
*If lung dz: consider max load 8-10mg/kg
ED IV Phenobarb Load: active severe w/d, CIWA >15, 2+ of (HR>110, SBP >140, diaphoresis, tongue fasc). Must stay 1hr in ED after IV load. NO MORE IM after IV unless re-load (see below). Start PO 8hrs after IV load.
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