Reference: Borgundvaag et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department. AEM May 2024 Date: May 22, 2024 Dr. Bjug Borgundvaag Guest Skeptic: Dr. Bjug Borgundvaag is the Founding Director of the Schwartz/Reisman Emergency Medicine Institute (SREMI), at Sinai Health System. He is a Professor of Emergency Medicine and a Clinician Scientist in the Department of Family and Community Medicine at U of T. Prior to his medical training, he completed a PhD in Pharmacology at U of T. He has been involved in ED-based clinical research examining ways to improve care for patients with alcohol use disorder in the ED for over two decades. This is an SGEM HOP but with a twist. We are not going to do a structured critical appraisal of GRACE4 but rather turn it into an SGEM Xtra. When we combine SGEMHOP with an SGEM Xtra I hope we get some…AMAZING knowledge translation for GRACE4. "The SAEM GRACE program addresses the best practices for the care of the most common chief complaints that can be seen on the tracking board of any emergency department in the country, based upon research and expert consensus. These guidelines are designed with de-implementation as a guiding principle to reasonably reduce wasteful testing, provide explicit criteria to reduce foreseeable risk, and define sensible and prudent medical care." GRACE1: Recurrent, Low-Risk Chest Pain GRACE2: Recurrent, Low-Risk Abdominal Pain GRACE3: Acute Dizziness & Vertigo For this SGEMHOP Xtra combo episode on GRACE4, we are going to give a case scenario, a little background information, ask a clinical question, provide authors’ conclusions, go through the recommendations and a case resolution. Case 1: A patient presents to the ED with nausea, vomiting and some abdominal pain complaining of alcohol withdrawal. He reports that his last drink was 9 hours ago, and he typically consumes 60 oz of spirits/day. He has had prior hospital admissions for the management of alcohol withdrawal, including seizures and one prior episode of delirium tremens. Management: The patient is initiated on a Clinical Institute Withdrawal Assessment (CIWA) protocol and administered intravenous (IV) doses of diazepam hourly for the next 18 hours. There was a 6-hour delay until the first dose of diazepam was administered. Over those 18 hours, his CIWA stubbornly stays at around 18, and by the 15-hour mark, has increased to 21 despite receiving 20mg of diazepam hourly. By the 18-hour mark, he has had a total of 240 mg of diazepam and is getting worse. Clinical Question 1: Is IV phenobarbital, in addition to diazepam, helpful in managing this case of severe alcohol withdrawal? Authors’ Conclusions: There is limited direct high-quality evidence from clinical trials supporting the use of phenobarbital as an adjunct to benzodiazepines for managing moderate to severe AWS in the ED setting. Although the direct prospective evidence comparing these interventions in ED patient populations is limited, the balance between desirable and undesirable effects favours adjunctive phenobarbital over benzodiazepine alone. This is based, in large part, on indirect evidence illustrating the benefits of adjunctive phenobarbital including, but not limited to, reduction on the need for intubation, decreased hospital length of stay, decreased ICU admission and length of stay. Recommendation 1: In adult ED patients (over the age of 18) with moderate to severe alcohol withdrawal, who are being admitted to the hospital we suggest using phenobarbital in addition to benzodiazepines as compared to using benzodiazepines alone. (Conditional recommendation, FOR) [Low to Very Low certainty of evidence] Good practice statement: All patients treated for alcohol withdrawal should be offered follow-up treatment where such treatment is available.