Unplanned alcohol withdrawal (Guidelines)

GMAWS is a validated tool for use in acute general hospitals. This tool has been implemented for use in acute general and community hospitals in NHS Highland, replacing the old Diazepam scoring.

• The protocol encourages prescribers to risk assess patients high risk for severe withdrawal or high risk for over sedation (called exceptional patient group).
• In GMAWS the high risk for severe withdrawal receive fixed dose diazepam to achieve better symptom control.
• High risk patients for over sedation receive less benzodiazepine to protect them for harm of over sedation.
• The protocol also has guidance on thiamine prescribing in patients with alcohol withdrawal.

GMAWS chart: 

• Printed charts are available on wards.
• Replacement charts for wards can be ordered via PECOS. Code: WZS230
• On line version can be accessed: Glasgow Management of Alcohol Withdrawal Score (GMAWS)
• NB For detailed advice re adjunctive therapy with haloperidol, refer to NHS Highland's Rapid tranquilisation (Guidelines)
•  in place of GGC guidance (as is directed in GMAWS document).
• For prescribing diazepam, use the HEPMA GMAWS protocol or prescribe on a paper Kardex, depending on which is in use in your area. 

• Contact the mental health liaison team if advice is required to manage alcohol withdrawal on: extension 6224.
• In Raigmore: Contact Ward GA bleep holder (bleep 4000) to discuss admission to medicine if unplanned alcohol detoxification is indicated.
• In a Community or Rural General Hospital: contact the senior clinician responsible for admissions.

Medical review of the prescription is required if the patient is excessively drowsy.

• Consider switching to lorazepam or diazepam at 50% of the standard dose.

Senior medical review (ST3 or above) is required if the patient:

• Requires more than 120mg diazepam in 24hours
• Fails to improve after two doses of benzodiazepine
• Has an alcohol withdrawal seizure
• Still requires full dose treatment 96hours after the last alcohol ingestion. Consider differential diagnoses and review the need for possible adjuncts (haloperidol or olanzapine).

Any patients requiring intravenous benzodiazepines should be assessed by a senior decision maker and considered for care in a level one enhanced care facility or above.

An alternative alcohol withdrawal protocol CIWA-AR (Clinical Institute Withdrawal Assessment - Alcohol Recovery) is used in New Craig’s Hospital for planned alcohol detoxification.

• NICE CG115: Alcohol Use Disorders
• BMJ best practice: Alcohol Withdrawal