Alcohol Withdrawal Observation Chart

Alcohol Withdrawal Observation Chart (1)

Surname: Date of Birth: Sex:

Age: Weight:

When alcohol withdrawal is predicted, it is appropriate to load the patient with diazepam prior to significant withdrawal becoming evident.

However, at times alcohol withdrawal may complicate an admission for another reason (e.g. surgery, pneumonia etc) and the first indication is when alcohol withdrawal becomes evident and requires treatment. Advice re appropriate protocols is provided on page 4.

1. Average daily alcohol consumption during the past week

grams ( = standard drinks x 10)

Withdrawal is unlikely if alcohol consumption <80 grams daily

2. Date and time of last drink

Date: Time: Hours:

Onset of alcohol withdrawal usually 6-24 hours from last drink although may be delayed

3. Breath alcohol reading

grams percent at hours

Diazepam should not be given until the breath alcohol reading is 0.1%

4. Notify a doctor if:

§ Previous withdrawal seizures

§ Delirium tremens (disorientation, confusion, hallucinations, automatic hypoactivity e.g. sweating, fever, tachycardia, dilated pupils at ≥48 hours)

§ Recent benzodiazepine use (this may affect the expression of alcohol withdrawal symptoms)

§ Recent/suspected head injury

§ Patient not easily rousable to speech

§ Respiratory disease

§ Oxygen saturation <94% (on air)

§ Respiratory rate <8 or >25 breaths per minute

§ Severe liver disease

§ Other medications especially CNS depressants (e.g. opioids) are prescribed/taken

5. Environment

Low stimulation, reassurance, reorientation and even lighting are important factors in observing a patient accurately.

Care by the same nurse for each shift is desirable and reduces likelihood of complications.

6. Thiamine (to prevent acute Wernicke’s Syndrome) must be given before any form of glucose loading

Moderate-Severe withdrawal predicted (determine at risk of Wernicke’s): thiamine 100mg IM tds for 3 days then oral thiamine 100 mg per day for one week. Daily oral multivitamin and mineral supplement.

Mild withdrawal predicted (not determined at risk of Wernicke’s); One dose thiamine 100 mg IM then thiamine 100 mg orally daily. Daily oral multivitamin and mineral supplement.

7. Diazepam: commence when BAC 0.1%

If withdrawal is predicted it is prudent to follow the weight related loading instructions (refer to protocol 1). If there is a history of alcohol withdrawal seizures then the seizure prophylaxis regime should be followed. For unexpected alcohol withdrawal complicating medical/surgical admission refer to Protocol 2.

8. Alcohol Withdrawal Score (AWS) should be monitored hourly during

loading, thereafter:

§ Hourly if AWS >20

§ 2 hourly if AWS 8-20

§ 4 hourly if AWS <8

§ if score fails to settle with prescribed diazepam or rises >15 the doctor should be notified

9. Symptomatic treatment (e.g. for headache, nausea and vomiting) may be useful:

§ Paracetamol: 500 mg – 1 mg oral 4-6 hourly prn

§ Metoclopramide: 10 mg oral IM tds prn

Alcohol Withdrawal Assessment Chart (2)

Nausea and vomiting

Ask ‘Do you feel sick in the stomach? Have you
vomited?’
Observation
No nausea and no vomiting
0 Mild nausea with no vomiting
1
2
3
4 Intermittent nausea, with dry retching
5
6
7 Constant nausea, frequent dry retching and vomiting

Tremor

Arms extended, elbows slightly flexed and fingers spread.
Observation
0 No tremor
1 Not visible, but can be felt fingertip to fingertip
0
3
4 Moderate
5
6
7 Severe even with arms not extended

Paroxysmal sweats

Observation
0 No sweats visible
1 Barely perceptible sweating, palms moist
2
3
4 Beads of sweat obvious on forehead
5
6
7 Drenching sweats

Anxiety

Ask ‘Do you feel nervous?’ Observation
0 No anxiety, at ease
1 Mildly anxious
2
3
4 Moderately anxious or guarded so anxiety is inferred
5
6
7 Equivalent to acute panic states as seen in severe
delirium or acute schizophrenic reactions

Agitation

Observation
0 Normal activity
1 Somewhat more than normal activity
2
3
4 Moderately fidgety and restless
5
6
7 Paces back and forth during most of the interview or
Constantly thrashes about /

Tactile disturbances

Ask ‘Have you any itching, pins and needles sensations, any burning,
any numbness or do you feel bugs crawling on or under your skin?’
Observation
0 None
1 Very mild itching, pins and needles, burning or numbness
2 Mild itching, pins and needles, burning or numbness
3 Moderate itching pins and needles, burning or numbness
4 Moderate severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations

Auditory disturbances

Ask ‘Are you more aware of sounds around you? Are they harsh?
Do they frighten you? Are you hearing anything that is disturbing you?
Are you hearing things that are not there?’ Observation
0 Not present
1 Very mild sensitivity
2 Mild sensitivity
3 Moderate sensitivity
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations

Visual disturbances

Ask ‘Does the light appear to be bright? Is its colour different? Does it
hurt your eyes?’
Are you seeing things that are not there?
Observation
0 Not present
1 Very mild sensitivity
2 Mild sensitivity
3 Moderate sensitivity
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations

Headaches, fullness in the head

Ask ‘Does your head feel different? Does it feel as though there is a
band around your head?’
Do not rate for dizziness or light headedness
Otherwise rate severity
0 Not present
1 Very mild
2 Mild
3 Moderate
4 Moderate severe
5 Severe
6 Very severe
7 Extremely severe

Orientation and clouding sensorium

Ask ‘What day is this? Where are you? Who am I? Observation
0 Orientated and can do serial additions
Ask person to perform serial addition of 3s up to 30 e.g. 3,6,9
1 Cannot do serial addition or is uncertain about date
2 Disorientated by date, no more than 2 calendar days
3 Disorientated for date, more than 2 calendar days
4 Disorientated for place and/or person

Alcohol Withdrawal Observation Chart (3).

Observations

Surname First Name Age

Date
Time
Breath alcohol reading
Blood glucose reading
Temperature (per axilla)
Pulse
Respiration rate
Blood pressure
Alcohol Withdrawal Assessment Score
Nausea
Tremor
Paroxysmal sweats
Anxiety
Agitation
Tactile disturbances
Auditory disturbances
Visual disturbances
Headache, fullness in head
Orientation and clouding of sensorium
TOTAL SCORE

AWS score

<8 Mild withdrawal

8-25 Moderate to severe withdrawal

>25 Very severe withdrawal

Checklist

- diazepam protocol

- thiamine 100 mg IM/IV on first day

- ensure adequate hydration

- refer to page 1 & 4 for appropriate management

Cited in DeCrespigny, C. et al. 2003, Alcohol Tobacco and Other Drugs Guidelines for Nurses and Midwives: Clinical Guidelines Flinders University and Drug and Alcohol Services Council, Adelaide

Also available at www.dasc.sa.gov.au

Alcohol Withdrawal Observation Chart (4)

Medical Management of Acute Alcohol Withdrawal

When alcohol withdrawal is the reason for admission and assessed as likely to have moderate to severe (from the history), diazepam loading of the patient prior to significant withdrawal becoming evident is desirable – Protocol 1. However, when alcohol withdrawal complicates admission for another reason and the first indication is when alcohol withdrawal becomes evident, the appropriate action is to treat withdrawal according to the signs and symptoms experienced by the patient and reflected in the Alcohol Withdrawal Score (AWS) – Protocol 2.

Protocol 1:

a) Loading regime (when significant withdrawal is predicted): refer to Inpatient Alcohol Withdrawal:

Use of Diazepam

Loading with diazepam by weight is commenced – for the first day:

§ <75 kg: 20 mg oral 2 hourly for 3 doses (i.e. 60 mg total)

§ 75-90 kg: 20 mg oral 2 hourly for 4 doses (i.e. 80 mg total)

§ >90 kg: 20 mg oral 2 hourly for 5 doses (i.e. 100 mg total)

§ thereafter 20 mg diazepam oral 2 hourly until AWS score is 10 or less

§ further medical assessment is required for doses beyond 120 mg

§ if AWS score rises to 15 or more recommend diazepam 20 mg oral 2 hourly after medical assessment

§ diazepam 5-10 mg qid prn may be prescribed for subsequent days to a maximum of 4 days

§ temazepam 10-20 mg nocte prn may be prescribed for night sedation for 3 nights

b) Withdrawal convulsion prophylaxis (where there is a history of withdrawal seizures)

§ Day 0:

on the first day the patient should receive the above loading regime (to a minimum of 75 mg i.e. an additional 15 mg diazepam if the weight is <75kg)

§ Day 1 & 2:

Diazepam 10 mg oral bd

§ Day 3:

Diazepam 5 mg bd

If high AWS scores occur during the Day 0 loading phase, doses should be continued 2 hourly until the score is 10 or less.

Note: withhold diazepam only if there are signs of intoxication (short periods of sleep are allowable)

Protocol 2:

Alcohol withdrawal complicating other admission e.g. surgical procedures (and where intercurrent illness does not preclude diazepam)

§ AWS score <8: sedation is generally not necessary, reassurance and attention nursing environment usually sufficient. 4 hourly AWS observation.

§ AWS score 8-25: where intercurrent illness does not preclude, diazepam 10-20 mg oral 2 hourly until AWS 8 and clinical sedation achieved. 2 hourly AWS observations, if AWS score >20 more intense nursing supervision required, If >80 mg diazepam is needed 2 hourly oxygen saturation is recommended. If >120mg diazepam needed, seek specialist advice.

§ AWS score >25: medical emergency, seek specialist advice. Slow IV diazepam 5 mg over 3-5 minuted, repeated if necessary up to 4 times in the first 30 minutes.

Protocol 3:

Combined alcohol and benzodiazepine withdrawal

§ Diazepam loading (as in Protocol 1 or 2 above) with a minimum dose of diazepam on Day 0 equivalent to the stated dose of benzodiazepine intake (to a maximum of 80 mg). This is given as 20 mg oral 2 hourly.

§ Initially more diazepam may be required to manage acute alcohol withdrawal symptoms or to prevent convulsions. This should be given at a rate of 20 mg 2 hourly until the score has settled.

§ During subsequent days inpatients will require a continuing gradual diazepam withdrawal regime – usually reducing by 10 mg per day to 40 mg, thereafter by 5 mg per day. Doses are usually administered qid.

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