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    Prediction of Alcohol Withdrawal Severity Scale

    Screens hospitalized patients for complicated alcohol withdrawal (seizures, delirium tremens).
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    INSTRUCTIONS

    Use in patients ≥18 years old admitted to general floor, with or without history of alcohol abuse. Do not use in patients with active or uncontrolled seizure disorder.

    When to Use
    Pearls/Pitfalls
    Why Use

    • Patients ≥18 years old admitted to general floor, with or without history of alcohol abuse.

    • Do not use in patients with active or uncontrolled seizure disorder.

    • Complicated alcohol withdrawal syndrome (AWS) is defined as withdrawal hallucinosis, withdrawal-related seizures, or delirium tremens.

    • Not yet validated in non-English speaking patients.

    • Patients with active or uncontrolled seizure disorder, obtunded, or unable to understand the questionnaire were excluded from the study.

    • The majority of patients included in the studies were on general medical floors. A limited number of patients from the emergency department, surgical floors, and critical care units were included.

    • Other alcohol withdrawal tools like CIWA-Ar stratify severity of AWS and can be used sequentially with the PAWSS (i.e., use PAWSS to screen for those at high risk for AWS, then use CIWA-Ar to determine if treatment is needed) (Eloma 2018).

    • 10% of symptomatic individuals experience withdrawal-related generalized tonic-clonic seizures. If left untreated, about one-third of patients with withdrawal seizures will progress to delirium tremens.

    • Prevalence of at-risk or heavy alcohol use tends to be higher among adults actively seeking healthcare in the general population.

    • Most patients undergoing alcohol withdrawal experience uncomplicated AWS and only need supportive care, but up to 20% have complicated AWS (i.e., withdrawal hallucinosis, seizures, delirium tremens), which can result in substantial morbidity and up to 15% mortality if unrecognized. With aggressive prevention and recognition, mortality rates decrease to 1-4% (Schuckit 2014).

    • PAWSS Scores ≥4 were 93.1% sensitive and 99.5% specific for development of complicated AWS in prospective validation (Maldonado 2015).

    Threshold Criteria
    No
    Yes

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Management

    • Subjects at risk for alcohol withdrawal should be placed on symptom-triggered therapy.

    • May be used to inform which patients may be appropriate candidates for the CIWA-Ar protocol.

    Critical Actions

    PAWSS Scores ≥4 suggest high risk for complicated AWS. Prophylaxis and/or treatment may be indicated.

    Formula

    Threshold Criteria:

    • Patient consumed any amount of alcohol within the last 30 days, OR
    • Patient had a positive blood alcohol level (>200 mg/dL) upon admission

    If yes to either of the above, addition of the selected points:

    Criteria

    Points

    Ask the Patient:

    Have you been recently intoxicated or drunk within the last 30 days?

    No

    0

    Yes

    1

    Have you ever experienced previous episodes of alcohol withdrawal?

    No

    0

    Yes

    1

    Have you ever experienced withdrawal seizures?

    No

    0

    Yes

    1

    Have you ever experienced delirium tremens (DTs)?

    No

    0

    Yes

    1

    Have you ever undergone alcohol rehabilitation treatment (i.e., inpatient or outpatient treatment programs, or Alcoholics Anonymous attendance)?

    No

    0

    Yes

    1

    Have you ever experienced blackouts?

    No

    0

    Yes

    1

    Have you combined alcohol with other “downers” (e.g. benzodiazepines, barbiturates) during the last 90 days?

    No

    0

    Yes

    1

    Have you combined alcohol with any other substance of abuse during the last 90 days?

    No

    0

    Yes

    1

    Clinical Evidence:

    Blood alcohol level (BAL) >200 mg/dL on presentation

    No

    0

    Yes

    1

    Evidence of increased autonomic activity (i.e., HR >120, tremor, sweating, agitation, nausea)?

    No

    0

    Yes

    1

     

    Facts & Figures

    Interpretation:

    PAWSS Score

    Risk of complicated AWS*

    Likelihood ratio**

    <4

    Average

    0.07

    ≥4

    High

    174

    *Withdrawal hallucinosis, withdrawal-related seizures, or delirium tremens.

    **From Wood 2018.

    Evidence Appraisal

    Derivation study, Maldonado 2014

    • Design:

      • Systematic review and pilot prospective cohort.

      • n = 17.

    • Aim:

      • Identify clinical factors associated with the development of alcohol withdrawal syndromes.

      • Develop a tool for the prediction of alcohol withdrawal among patients at risk.

      • Conduct a pilot study to assess the validity of the tool.

    • Inclusion criteria:

      Age ≥18 years.

    • Exclusion criteria:

      Non-English speaking patients.

    • Outcomes:

      • Negative PAWSS (score <4): n = 13, 0% of patients developed moderate or severe AWS.

      • Positive PAWSS (score ≥4), n = 4, 100% of patients developed moderate or severe AWS.

    Validation study, Maldonado 2015

    • Design:

      • Prospective cohort study in two teaching hospitals.

      • n = 403.

    • Aim:

      Prospectively validate PAWSS.

    • Inclusion criteria:

      • Age ≥18 years regardless of probable or confirmed alcohol use.

      • Patients directly admitted from the emergency department or community settings to general medicine or surgery units.

      • Able to communicate in English.

    • Exclusion criteria:

      • Non-English speaking patients.

      • Patients unable to understand the questionnaire or participate in the study.

      • Patient transferred from outside hospitals.

      • Active or uncontrolled seizures.

      • Patient in active alcohol withdrawal upon presentation.

      • Too sick to participate as per primary team.

    • Outcomes:

      • Negative PAWSS (score <4), n = 374, 0.5% of patients developed moderate or severe AWS.

      • Positive PAWSS (score ≥4), n = 29, 93.1% of patients developed moderate or severe AWS.

      • Sensitivity 93.1%, specificity 99.5%, PPV 93.1%, NPV 99.5%.

    Literature

    Dr. Jose R. Maldonado

    About the Creator

    Jose R. Maldonado, MD, FAPM, FACFE, is a professor of psychiatry and behavioral sciences at Stanford University Medical Center. He is also the medical director of psychosomatic medicine and chief of psychiatric emergency services and transplant psychiatry at Stanford University Medical Center. Dr. Maldonado’s research focuses primarily on solid organ transplantation, delirium, and neuropathophysiology of alcohol withdrawal syndrome.

    To view Dr. Jose R. Maldonado's publications, visit PubMed

    Content Contributors
    About the Creator
    Dr. Jose R. Maldonado
    Content Contributors