psychiatry emergency

Prediction of Alcohol Withdrawal Severity Scale (PAWSS)

10-item tool to predict complicated alcohol withdrawal (seizures, delirium tremens) in medically ill adults. Use it only if the patient has drunk alcohol in the last 30 days or has a positive blood alcohol level on admission. Score ≥ 4 = high risk.

Used in: Seizures & Epilepsy

1. Have you been intoxicated / drunk within the last 30 days?*

2. Have you ever undergone alcohol use disorder rehabilitation treatment or treatment for alcoholism (inpatient or outpatient programmes, or AA attendance)?*

3. Have you ever experienced previous episodes of alcohol withdrawal, regardless of severity?*

4. Have you ever experienced blackouts?*

5. Have you ever experienced alcohol withdrawal seizures?*

6. Have you ever experienced alcohol withdrawal delirium (delirium tremens)?*

7. Have you combined alcohol with other 'downers' (e.g. benzodiazepines, barbiturates) in the last 90 days?*

8. Have you combined alcohol with any other substance of abuse in the last 90 days?*

9. Blood alcohol level ≥ 200 mg/dL (≥ 43.4 mmol/L) on presentation*

10. Evidence of increased autonomic activity (e.g. heart rate > 120/min, tremor, sweating, agitation, nausea)*

Score interpretation

Low Risk 0–3

PAWSS 0–3 — low risk of complicated alcohol withdrawal

→ Standard monitoring; oral thiamine; symptom-triggered benzodiazepines (CIWA-Ar guided); reassess at 6 and 12 hours

High Risk 4–10

PAWSS ≥ 4 — high risk of complicated withdrawal (sensitivity 93.1%, specificity 99.5% in medically ill inpatients; Maldonado 2015)

→ Prophylactic benzodiazepine regimen (fixed-schedule diazepam or chlordiazepoxide); IV thiamine (Adults: Pabrinex 2 pairs TDS × 2 days. Children: use a children's formulary.); admit to monitored bed; seizure precautions; may require ICU-level care if deteriorates

Interpretation bands for the PAWSS. Apply clinical judgement and local guidance.

References

Maldonado JR, et al. The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol. 2014;48(4):375–390.
Maldonado JR, et al. Prospective Validation Study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in Medically Ill Inpatients. Alcohol Alcohol. 2015;50(5):509–518.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Pathways

Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.

Score interpretation

References

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