Western Health
Alcohol Withdrawal
Procedure code:
Effective date:
Last review date: December 2007
Next review date:
Policy:
Sub-section:
1. Overview
To inform clinical staff of the procedure to effectively manage patients/consumers who are identified at risk of alcohol
withdrawal in hospital.
2. Responsibility
Nurse Unit Managers
Head of Unit
Department Heads
Clinical staff
3. Authority
Head of Unit - Addiction Medicine
4. Applicability
Medical staff and Nursing staff in clinical areas
5. Associated Procedures/Instructions
In support of this procedure, the following Manuals, Policies, Instructions, Guidelines, and/or Forms apply:
Name: Alcohol Withdrawal Scale (AWS).
Number:
6. Procedure Detail
6.Overview
Any patient who may be at risk to develop Alcohol Withdrawal Syndrome while in hospital should be identified and
offered appropriate management.
6.1 Alcohol Withdrawal Risk
A patient might have one or more of the following characteristics:

Drinks on five or more days each week,

Consumes six or more drinks (alcoholic beverage in standard drinks) per day (NB especially elderly &
patients with significant liver disease).

A past history of alcohol withdrawal syndrome and/or DT (Delirium Tremens).

Patient has a current diagnosis of alcohol dependence syndrome (i.e. 'alcoholic').
6.2 Management in hospital
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
Once a patient at risk has been identified, the medical officer should prescribe appropriate doses of
Thiamine, Multivitamins and prophylactic Diazepam for both symptom relief and to minimise the risk of
withdrawal complications.

Nursing staff should refer to the Alcohol Withdrawal Scale (AWS) as a guide to patient treatment
response and to guide them about the potential need for additional medication (eg, Further Diazepam
dosing etc.)

Prompt institution of treatment usually attenuates the duration and severity of the Alcohol Withdrawal
Syndrome.

Alcohol withdrawal syndrome in all hospitalised alcoholics is lik ely to be more severe, especially when
there is a co-existing medical or surgical illness (i.e. Fever, sepsis, pain, and other stressors).

Liaison with the Drug & Alcohol Service is recommended especially in cases of severe of otherwise
complicated Alcohol Withdrawal reactions
6.3 Nursing Assessment

A patient identified at risk of Alcohol Withdrawal syndrome should be commenced on an Alcohol
Withdrawal Scale (AWS).

The patient is to be assessed utilising the AWS:
o Upon admission
o 1 hour after the loading doses
o 4 hourly thereafter for 24 hours
o HMO review daily for continuation of AWS

The time of assessment & the score must be documented on the AWS.

A score of 6 or more indicates a significant alcohol withdrawal response and should prompt a dosing with
diazepam.
6.4 Treatment
All patients should receive Thiamine supplementation (eg. 100mg daily or more) and have any electrolyte
abnormality (hypokalemia & hypomagnesemia are quite common) corrected. The treatment for Alcohol
Withdrawal may sometimes only require supportive nursing care but in hospitalised alcoholics, there is more
likely to be a requirement for pharmacotherapy to treat withdrawal symptoms. Furthermore, the use of
pharmacotherapy (i.e. usually benzodiazepines like Diazepam etc) early as “prop hylaxis” can reduce the risk
of the Alcohol Withdrawal Syndrome’s progression and development of complications eg. Seizures, delirium
etc.

Diazepam is provided in one of two ways:
o
Firstly as “Symptom-Triggered” which means a dose is given according to the AWS score (eg. >6
gets 20mg Diazepam) or according to any “prn” provision made on the drug chart (eg. Diazepam
5 – 10mg prn) which is determined by patient request and nursing assessment;
o
The second way of providing Diazepam in Alcohol Withdrawal is to utilise this drug for
“Prophylactic” benefit i.e. a loading dose of 60mg (or more) given early but after the blood
alcohol level has fallen below 0.1gm% [< 22mmol] and as three sequential doses of 20mg 1 2hours apart; any further doses are given when the AWS score exceeds 6. The latter process
continues for 24 hours after which time, the HMO needs to review the patient. Any patient who
scores 9 or more ( = severe) should always receive 20mg and further doses as required until
their score falls consistently below 6. A maximum dose of 120mg Diazepam is considered
appropriate for most patients however there may be rare exceptions (eg. patient dependent upon
alcohol plus high regular doses of diazepam/other benzodiazepines): in such circumstances,
consultation with Addiction Medicine is highly recommended.
Precautions:

One hour after any dose of diazepam, the patient needs to be assessed for any signs of respiratory
compromise.

If signs of respiratory compromise are identified, withhold any further doses and contact the treating unit.
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6.5 Discharge Follow up
The patient should always be referred to Drug & Alcohol service to follow up care post discharge regarding their
alcohol consumption and suffering of a Withdrawal reaction whilst in hospital.
Consideration should be given to the initiation of relapse prevention/anti -craving medication prior to discharge
(i.e. Naltrexone; Acamprosate) for any patient who has required treatment for alcohol withdrawal.
Guidance may be obtained by contacting the Addi tion Medicine HMO via switchboard.
PROCEDURE
Refer to Alcohol Withdrawal Scale (AWS) attached.
FURTHER INFORMATION
Sample medication sheets available on 1 West
NUM Ward 1 West
Approval
Head of Addiction Medicine
7. References
Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C. A; and Sellers, E. (1989). Assessment of alcohol withdrawal: The
revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-AR). Br J Addict 84:1353-1357.
Foy, S. Mc Kay, S. Ling S., Bertram and Sadler. (2006). Clinical use of a shortened alcohol withdrawal scale in a general
hospital. Internal Medicine Journal.36, 150-154.
8. Document History
Number of revisions:
Issue dates:
9. Sponsor
Jenny Walsh - Divisional Director Medicine/COGS/Aged Care
10. Approval Authority
Head of Unit - Addiction Medicine
11. Authorisation Authority
Clinical Governance
Code and title of procedure
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The Alcohol Withdrawal Scale (AWS)
This protocol should be used in all patients withdrawing from alcohol.
INITIAL ASSESSMENT




Drinking history
Previous withdrawal episodes / complications
Current level of intoxication/withdrawal
Blood Alcohol Level (B.A.L.)
Is the patient in a state of alcohol withdrawal or at high risk of
developing severe withdrawal symptoms? (See below)
YES
Diazepam titration
regimen
NO
Observe 2-4 hourly as B.A.L. falls
to zero and subsequent 24 hours
Alcohol
withdrawal
pharmacotherapy
Diazepam Titration Regimen:
1. Without a loading dose: if uncomplicated withdrawal in the past or history uncertain
a. If AWS > 6 use diazepam 10-20mg PO hourly and monitor hourly.
b. If AWS< 6 observe 4 hourly. Diazepam 5-10mg up to q.i.d., p.r.n. may be used for mild
symptom relief.
c. Cease protocol if AWS < 10 for 24 hours following last diazepam dose. Diazepam is not
usually necessary for more than 3 days.
2. With a loading dose: If at high risk of severe withdrawal symptoms (past history of seizures, delirium
hallucinations or other severe withdrawal reactions OR if AWS > 6 before BAL <0.1%).
In addition to the above use:
a. Diazepam 20mg when B.A.L. <0.1% or AWS > 6 (which ever is the sooner) followed by:
b. Diazepam 20mg every hour until withdrawal symptoms settle and patient is lightly sedated.
Do not give once patient is sedated. Reassess the patient before administering more than
60mg. Consult with Addiction Medicine Physician before using more than 12 0mg.
c. Gradually taper diazepam over 3-5 days
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ALCOHOL WITHDRAWAL
SCALE
USERS REFER TO NURSING GUIDELINES WHERE AVAILABLE
N AM E:
U.R. No:
Address
D.O.B.
D AT E:
DR:
W A R D :(per axilla)
Temperature
D
A
T
E
T
I
M
E
Bradma Label
1) 37.0 – 37.5C
2) 37.6-38.0C
3) Greater than 38.0C
Pulse (beats per minute)
1) 90-95
3) 101-105 5) 111-120
2) 96-100
4) 106-110 6) Greater than 120
Respiration rate (inspiration per minute)
1) 20 –24
2) Greater than 24
Tremor (arms extended, fingers spread)
0) No tremor
2) Not visible – can be felt fingertip to fingertip
4) Moderate with arms extended
6) Severe even with arms not extended
Sweating (observation)
0) No sweat visible
2) Barely perceptible, palms moist
4) Beads of sweat visible
6) Drenching sweats
Visual disturbances (photophobia, seeing things)
0) Not present
2) Mild sensitivity (bothered by the lights)
4) Intermittent visual hallucinations (occasionally sees things you
cannot)
6) Continuous visual hallucinations (seeing things constantly)
Clouding of sensorium (“What day is this? What is this place?”)
0) Oriented
2) Disorientated for date by no more than two days
4) Disorientated for date
6) Disorientated for place (re-orientate if necessary)
Quality of contact
0)
2)
4)
6)
In contact with examiner
Seems in contact, but is oblivious to environment
Periodically becomes detached
Makes no contact with examiner
Agitation (your observation)
0)
2)
4)
6)
Normal activity
Somewhat more than normal activity
Moderately fidgety and restless
Pacing, or thrashing about constantly
Thought disturbances (flight of ideas)
0) No disturbance
2) Does not have much control over nature of thoughts
4) Plagued by unpleasant thoughts constantly
6) Thoughts come quickly and in a disconnected fashion
Alcohol withdrawal scale regime – NOTE CHANGE IN SCORE
1
Score 4th hourly routinely
2
If greater than 6 score 2nd hourly
3
If greater than 9 score hourly
TOTAL
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