II. Indications: Alcohol Detoxification

  1. Alcohol Withdrawal assessment
  2. Scale used to direct Benzodiazepine protocol

III. Technique

  1. Each criteria rated on scale of 0 to 7 (except orientation)
  2. Maximum score: 67

IV. Evaluation: Criteria

  1. Nausea, Vomiting
    1. Score 0: None
    2. Score 4: Intermittent
    3. Score 7: Constant
  2. Tremor
    1. Score 0: None
    2. Score 4: Tremor with Arms Extended
    3. Score 7: Severe Tremor at Rest
  3. Paroxysmal Sweating
    1. Score 0: None
    2. Score 1: Palms moist
    3. Score 4: Forehead beads of sweat
    4. Score 7: Drenched
  4. Anxiety
    1. Score 0: None
    2. Score 1: Mild
    3. Score 4: Moderate
    4. Score 7: Severe Panic Attack
  5. Agitation
    1. Score 0: None
    2. Score 4: Fidgets, Restless
    3. Score 7: Paces or thrashes
  6. Tactile Dysfunction
    1. Score 0: None
    2. Score 3: Paresthesias
    3. Score 5: Severe Tactile Hallucinations
    4. Score 7: Continuous Tactile Hallucinations
  7. Auditory Disturbances
    1. Score 0: None
    2. Score 4: Hallucinations
    3. Score 7: Continuous
  8. Visual Disturbances
    1. Score 0: None
    2. Score 2: Mild Light Sensitivity
    3. Score 4: Moderate Visual Hallucinations
    4. Score 7: Continuous Visual Hallucinations
  9. Headache
    1. Score 0: None
    2. Score 3: Moderate
    3. Score 5: Severe
    4. Score 7: Extreme
  10. Orientation
    1. Score 0: Oriented and Can Perform Serial Addition
    2. Score 1: Cannot Perform Serial Addition, Unsure of Date
    3. Score 2: Disoriented Regarding Date, But Within 2 Calendar Days
    4. Score 3: Disoriented Regarding Date By >2 Calendar Days
    5. Score 4: Disoriented to Place

V. Resources

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