` ALCOHOL WITHDRAWAL – ASSESSMENT & MANAGEMENT ON AMU 1. (affix patient label if available) Patient Name:................................................. PID:............................DOB: Date: DD/MM/YY Time: HH:MM Consultant: Name/grade of person completing form (print): HIGH RISK OF SEVERE ALCOHOL WITHDRAWAL? Indicated by ≥2 of the following: Presentation with or previous seizures secondary to alcohol withdrawal Previous severely agitated withdrawal or delirium tremens High screening score: FAST>12 (see BOX 1 below) High initial symptom score: GMAWS>9 (see BOX 3 overleaf) HIGHER FIXED-DOSE TREATMENT (FDT): see BOX 2 PLUS SYMPTOM-TRIGGERED TREATMENT (STT): see BOX 3 LOWER FIXED-DOSE TREATMENT (FDT): see BOX 2 PLUS SYMPTOM-TRIGGERED TREATMENT (STT): see BOX 3 BOX 1: FAST (Fast Alcohol Screen Test) Score Patient Score 0 1 2 3 4 1. How often have you had ≥6 units (female) or ≥8 units (male) on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily 2. How often during the last year have you failed to do what was normally expected from you because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily 3. How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never Less than monthly Monthly Weekly Daily or almost daily 4. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No Yes, but not in the last year Yes, during the last year TOTAL FAST SCORE (score of ≥3 = FAST positive): BOX 2: FIXED-DOSE TREATMENT (FDT) REGIMEN FOR PATIENTS AT HIGH RISK OF SEVERE WITHDRAWAL Day Morning Midday Evening Night Total Daily Dose 1 30mg 30mg 30mg 30mg 120mg 2 25mg 25mg 25mg 25mg 100mg 3 20mg 20mg 20mg 20mg 80mg 4 15mg 15mg 15mg 15mg 60mg 5 10mg 10mg 10mg 10mg 40mg 6 10mg 10mg - 10mg 30mg 7 10mg - - 10mg 20mg lower dose fixed regimens (starting with chlordiazepoxide 15-20mg QDS) should be used for patients NOT at high risk of severe withdrawal or if elderly, low BMI, significant hepatic/renal impairment or if excessive sedation develops using the regimen above; all fixed dose-regimens can be prescribed automatically on EP by typing ‘alcohol’ into the search box oral lorazepam (shorter half-life than chlordiazepoxide and less hepatic metabolism) may be used as an alternative if elderly, significant hepatic impairment, severe acute illness (e.g. pneumonia), cerebrovascular disease or head injury approximate oral benzodiazepine equivalence: 30mg chlordiazepoxide PO = 10mg diazepam PO = 1-2mg lorazepam PO patients unable to tolerate oral medication (e.g. due to vomiting) may be given IV diazepam or IV lorazepam at 50% of equivalent oral dose i.e. PO chlordiazepoxide 30mg = IV diazepam 5mg = IV lorazepam 0.5-1mg: SEEK SENIOR SUPPORT YES NO