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Yet another study (this time ED focused) has shown benefits to patients and hospital systems when implementing a Phenobarbital-based treatment algorithm. Shorter ED LOS, fewer admissions, and treatment with phenobarbital alone was independently associated with discharge when compared to mixed treatment regimens. Higher age and heart rate, as well as treatment with benzodiazepines alone were independently associated with hospitalization.
Cautions/contraindications include: pregnancy, cirrhosis with history of hepatic encephalopathy (consider dose reduction in hepatic dysfunction), acute intermittent porphyria, and prior chronic phenobarbital use.
Phenobarbital has a long half life (one of its benefits in AWS) and works synergistically with benzodiazepines, so should be used preferentially as monotherapy in patients where the diagnosis is relatively certain and who have not received high doses of benzos. Once the diagnosis is made, go with phenobarbital and stick with it.
PulmCrit has an excellent in-depth article on this and also see Dr. Flint's pearl describing another centers experience in a hospital-wide rollout (links below).
References
- https://pubmed.ncbi.nlm.nih.gov/41147831/
- https://umem.org/educational_pearls/4885/
- https://emcrit.org/ibcc/etoh/#pitfalls_of_phenobarbital