How to use it
- Observe the patient for tremor, sweating and agitation, and ask the questions in each item.
- Pick the rating for each item. In-between numbers are for findings between the described anchors.
- Read the total and the severity group, and repeat at the interval your protocol sets.
How the scale works
Nine items (nausea and vomiting, tremor, sweats, anxiety, agitation, tactile, auditory and visual disturbances, headache) are rated 0 to 7. Orientation is rated 0 to 4. The total is their sum, up to 67.
| Total | Withdrawal |
|---|---|
| 0–8 | Absent or minimal |
| 9–15 | Moderate |
| 16 or more | Severe |
Protocols differ slightly in these cut-offs; some use 10 rather than 9 as the start of moderate withdrawal.
Worked example
Twelve hours after his last drink a patient has mild nausea (1), a moderate tremor with arms extended (4), beads of sweat on his forehead (4), is moderately anxious (4) and a little restless (1), with no hallucinations, no headache and normal orientation. The total is 1 + 4 + 4 + 4 + 1 = 14, moderate withdrawal.
Tips
- The scale assumes the symptoms come from alcohol withdrawal; infections, low blood sugar and other drugs can cause similar signs.
- A patient who cannot communicate cannot be scored reliably.
- Scores change quickly, so record the time of each assessment.
- This page is for information. Alcohol withdrawal can be dangerous and needs medical care.