Phenobarbital for alcohol withdrawal: rapid patient disposition.

THE CALIFORNIA JOURNAL OF EMERGENCY MEDICINE A publication from the California Chapter of the American Academy of Emergency Medicine July 2000 President’s Message July 2000 will always be perhaps a special moment for CAL/AAEM. We are now moving forward with the first issue of our newsletter: the California Journal of Emergency Medicine. In less than two years and with only 200 California AAEM members, we have organized so far 3 successful widely-publicized Business Forums on critically important practice issues in emergency medicine (EM). We have supported emergency physicians (EPs) in their legal struggles for due process. We have recruited an impressive panel of EPs to our board of directors and to the leadership of almost every committee. Perhaps our most important effort has been in our opposition to the “Corporatization of EM” by publicly held and hospital owned entities. We have targeted “Exit Strategies” as our most important priority due its critically damaging impact on the welfare of the majority of EPs. CAL/AAEM stood unequivocally united with the CMA, ACHP and our own AAEM in supporting nearly 40 EP groups in their struggle to stand against what we believe is a dangerous violation of the California laws prohibiting the corporate practice of medicine by non-physician entities. We are also actively progressing in our work with the State Medical Board to address the issue of moonlighting while emphasizing the value of board certification in EM as a requirement for the independent practice of EM. Our patients deserve nothing less. I would like to dedicate the first issue of our newsletter and my first CAL/AAEM President’s message to CAL/ACEP. As EPs, united, we must all express our gratitude to CAL/ACEP for its long-standing dedication and its achievements on a state and national level. We also wish to thank its members and its current past and current leadership for the outstanding services CAL/ACEP has provided to all EPs on nearly every front. You equally touch the lives of your members and non-members. Many of our members and readers will next ask “Then why a second state organization?” Why not maintain a cohesive one- organization approach in California? Why even join CAL/AAEM? Those are indeed most legitimate questions. A second “organized EM voice” in California certainly carries the risk of weakening our efforts. It could be labeled as “divisive” and demoralizing. Why not simply participate and contribute effectively to a more resourceful experienced organization? Furthermore, CAL/ACEP is actually an organization that has recently embraced our participation. In June 2000, its members have elected three of our AAEM leaders to its own board of directors. CAL/ACEP has enriched us with many of our own AAEM members who are dual in their affiliations, including 3 of its own past Presidents. Even the EMPAC Board has at least 3 of our own AAEM members. (Cont. on page 2) Volume I, Number 1 Welcome Welcome to the first issue of The California Journal of Emergency Medicine. This journal is a quarterly journal dedicated to providing CAL-AAEM and other physicians up-to- date information on the practice of emergency medicine – both clinical and practical. Submissions are welcome and encouraged. It’s your forum for communication! Types of submissions include: 1. Viewpoint: Brief statement on a controversial topic (maximum 400 words). 2. Case Report 3. Review articles (maximum 1000 words) 4. Letter to the Editor: Response to published article 5. Original research Robert Derlet, MD Editor Address: Emergency Department UC Davis Medical Center 2315 Stockton Boulevard, PSSB 2100 Sacramento, CA 95817 Clinical Review Phenobarbital for Alcohol Withdrawal: Rapid Patient Disposition John R. Richards, M.D. U.C. Davis School of Medicine For thousands of years, ethanol abuse continues to be a serious problem worldwide. Emergency physicians face the consequences of alcoholism. Chronic alcoholics often present to the emergency department with seizures, ketoacidosis, and symptoms of withdrawal. These patients require significant physician time, nursing, and medical resources. For sedation and reversal of withdrawal symptoms, benzodiazepines (BZDs) have most commonly been utilized in the (ED) and intensive care unit setting. Phenobarbital is an older drug that is perhaps currently underutilized for alcohol withdrawal. In this article I will discuss the advantages of phenobarbital over BZDs in the rapid disposition of chronic alcoholic patients. The pharmacologic action of the diminutive ethanol molecule is complex. It is believed to increase the fluidity of the lipid bilayer of cell membranes within the central nervous system, resulting in alteration of membrane function from diminished viscosity. One example of this is the enhanced action of the inhibitory neurotransmitters GABA and glutamate at their respective receptors in the presence of ethanol. Ethanol also appears to affect opioid receptors, as well as many other membrane-bound enzymes and ion channels. A variety of pharmacologic agents have been tried in the past for withdrawal. Besides BZDs and phenobarbital, other anticonvulsants, such as phenytoin, have been used with limited success. Phenytoin has little efficacy in the mitigation of withdrawal symptoms, and does (Cont. on page 3)