Prediction of Alcohol Withdrawal Severity Scale

PAWS Calculator

Blood Alcohol Level (BAL) on Admission

Previous Alcohol Withdrawal Seizures

Previous Delirium Tremens (DTs)

Concurrent Illness

Prior Detox Admissions

Days Since Last Drink

Combined Substance Use

Previous Withdrawal Episode

Positive BAL without Intoxication

Heart Rate >120 bpm

PAWS Score: –

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Predicts risk of severe alcohol withdrawal in hospitalized patients.

Why Use

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 ).

When to 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.

Formula

Threshold criteria: Patient consumed any amount of alcohol within the last 30 days, OR Patient had a positive blood alcohol level 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: Positive blood alcohol level (BAL) on presentation No 0 Yes 1 Evidence of increased autonomic activity (i.e., HR >120, tremor, sweating, agitation, nausea)? No 0 Yes 1 From Maldonado 2015 .

Pearls / Pitfalls

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.

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.

More Information

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 .