PAWSS: Prediction of Alcohol Withdrawal Severity Scale (Maldonado 2014)
PAWSS, the Prediction of Alcohol Withdrawal Severity Scale, estimates the risk of complicated alcohol withdrawal in someone who has been drinking recently. A threshold question comes first: has the person had any alcohol in the last 30 days, or a positive blood alcohol level on admission? If yes, ten items are each worth 1 point. A total of 0 to 3 is low risk and 4 or more is high risk. Magent's PAWSS calculator adds the items you mark and returns the score and the risk group.
Not a medical device. Not a diagnosis or dosing recommendation.
What is PAWSS?
Maldonado and colleagues built PAWSS to pick out, early in a hospital stay, people at higher risk of complicated withdrawal: seizures, delirium tremens or a severe course. Most items come from the person's history, and two come from how they present.
PAWSS looks ahead at risk. It isn't a withdrawal severity scale like CIWA-Ar, which rates symptoms already present.
The PAWSS scoring
Threshold (0 points): any alcohol in the last 30 days,
or a positive blood alcohol level on admission
no -> score 0, outside the scale's window
yes -> add 1 point for each item present:
History
- intoxicated within the last 30 days
- ever in rehabilitation for alcohol use, or Alcoholics Anonymous
- any previous alcohol withdrawal
- ever had blackouts
- ever had withdrawal seizures
- ever had delirium tremens
- alcohol combined with benzodiazepines or barbiturates, last 90 days
- alcohol combined with any other substance of abuse, last 90 days
On presentation
- blood alcohol level 200 or more
- signs of increased autonomic activity
score 0-10: 0-3 low 4 or more highExact expression the calculator uses:
PAWSS = if alcohol_last_30d_or_positive_bal then recently_intoxicated_30d + alcohol_rehab + previous_withdrawal + blackouts + withdrawal_seizures + delirium_tremens + combined_downers_90d + combined_other_substances_90d + bal_ge_200 + increased_autonomic_activity else 0; each item 1 if true; Part A threshold 0 points; max 10; threshold false → outside_window; 0-3 low; >=4 high; Maldonado 2014Inputs
| Input | Meaning |
|---|---|
alcohol_last_30d_or_positive_bal | Threshold, worth 0 points |
recently_intoxicated_30d | Intoxicated within 30 days |
alcohol_rehab | Ever in alcohol rehabilitation or Alcoholics Anonymous |
previous_withdrawal | Any previous withdrawal |
blackouts | Ever had blackouts |
withdrawal_seizures | Ever had withdrawal seizures |
delirium_tremens | Ever had delirium tremens |
combined_downers_90d | Alcohol plus benzodiazepines or barbiturates in 90 days |
combined_other_substances_90d | Alcohol plus another substance of abuse in 90 days |
bal_ge_200 | Blood alcohol level of 200 or more on presentation |
increased_autonomic_activity | For example heart rate above 120, tremor, sweating, agitation or nausea |
Every input is a yes/no that you assign from the history and the person's presentation. The calculator doesn't interview anyone or measure blood alcohol.
How the calculation works
- Threshold. If there has been no alcohol in the last 30 days and no positive blood alcohol level, the score is 0 and the result is marked outside_window. The ten items aren't added.
- Items. Otherwise, each of the ten items present adds 1.
- Group. A total from 0 to 3 is low; 4 or more is high. There's no middle group.
Worked examples
These use Magent's own expected values for the calculator.
Example 1: no alcohol in the last 30 days
- Threshold no.
- Score 0, outside_window.
Example 2: threshold met, no items
- Threshold yes, all ten items no.
- Score 0, low.
Example 3: one item, past withdrawal seizures
- Threshold yes, withdrawal seizures yes.
- Score 1, low. Increased autonomic activity on its own also gives 1.
Example 4: three items
- Threshold yes; recent intoxication, rehabilitation and previous withdrawal yes.
- Score 3, low.
Example 5: four items
- As example 4, plus blackouts.
- Score 4, high.
Example 6: items marked but threshold not met
- Threshold no, even with all ten items marked yes.
- Score 0, outside_window. The items aren't counted unless the threshold is met.
History of PAWSS
Maldonado JR and colleagues published PAWSS in Alcohol in 2014, in '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'. They chose the items from a search of published risk factors and then tried the scale in a pilot group of hospital patients.
When it's used
PAWSS is filled in early in a hospital stay for someone who has been drinking in the last month, to flag a higher risk of complicated withdrawal.
Where it's used
Medical and surgical wards, emergency departments and consultation-liaison psychiatry.
Who uses it
Physicians, nurses and psychiatrists who take the alcohol history. The calculator adds the items and applies the 4-point cut-off.
Limits of the calculation
- It depends on an accurate history, which may be hard to get from someone unwell or intoxicated.
- The pilot group was small, so figures from it are rough.
- It predicts risk. It doesn't measure withdrawal symptoms.
- The calculator gives a group, not a plan of care.
- This page doesn't say what a result means for a particular person.
Clinical decisions belong to a qualified clinician who knows the patient.
How it differs from related calculators
Glossary
- Complicated withdrawal: withdrawal with seizures, delirium tremens or a severe course.
- Delirium tremens: a severe withdrawal state with confusion and autonomic overactivity.
- Autonomic activity: signs such as a fast heart rate, sweating and tremor.
- Threshold question: the first question; it scores 0 but decides whether the items count.
Common mistakes
- Scoring the threshold as a point. It's worth 0 and works as a gate.
- Adding items when the threshold isn't met. The score stays 0.
- Using PAWSS to rate current symptoms. That's what CIWA-Ar is for.
- Inventing a middle group. The groups are 0 to 3 and 4 or more.
Source
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. DOI: 10.1016/j.alcohol.2014.01.004. PMID: 24657098
Frequently asked questions
What is a high PAWSS score?
4 or more out of 10.
Is PAWSS the same as CIWA-Ar?
No. CIWA-Ar rates withdrawal symptoms that are already present. PAWSS estimates the risk of complicated withdrawal from the history and presentation.
What happens if the person hasn't drunk alcohol in the last 30 days?
If the blood alcohol level on admission is also negative, the threshold isn't met. The score is 0 and the result is outside the scale's window.
What is the maximum PAWSS score?
10, one point for each item.
Does the calculator measure blood alcohol?
No. You mark whether the level was 200 or more.