II. Indications: Alcohol Detoxification

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

III. Scale Criteria

  1. General
    1. Each rated on scale of 0 to 7 (except orientation)
    2. Maximum score: 67
  2. Nausea, Vomiting (0 none, 4, intermittent, 7 constant)
  3. Tremor (4 Tremor with arms extended, 7 Tremor at rest)
  4. Paroxysmal sweating (1 palms, 4 forehead, 7 drenched)
  5. Anxiety (1 mild, 4 moderate, 7 severe Panic Attack)
  6. Agitation (4 fidgets, 7 paces)
  7. Tactile Dysfunction (3 Paresthesias, 7 continuous)
  8. Auditory Disturbances (4 Hallucinations, 7 continuous)
  9. Visual Disturbances (4 Hallucinations, 7 continuous)
  10. Headache (0 none, 3 moderate, 5 severe, 7 extreme)
  11. Orientation (0 serial addition, 4 disoriented to place)

IV. Resources

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