Download Alcohol Withdrawal Observation Chart - NCETA

B4: 1 Alcohol HO13
Alcohol Withdrawal Observation Chart (1)
Surname:
Date of Birth:
Age:
Sex:
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:
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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:
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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:
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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
Tactile disturbances
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
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
Tremor
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
Auditory disturbances
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
Visual disturbances
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
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
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
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:
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<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)
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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
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b)
Withdrawal convulsion prophylaxis (where there is a history of
withdrawal seizures)
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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)
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AWS score <8: sedation is generally not necessary, reassurance
and attention nursing environment usually sufficient. 4 hourly AWS
observation.
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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.
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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
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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.
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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.
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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.
© Drug & Alcohol Services Council 2001: Revised 2003
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