Quick reference algorithm
Adult trauma and SICU patients · October 2026 edition
Complete PAWSS assessment on admission
PAWSS itemsScreening tool to identify hospitalized patients at high risk for complicated alcohol withdrawal.
Step 1
Loading dose
800 mg PO
Taper begins 6 h after loading dose
| Day 1–2 | 600 mg PO QID |
|---|---|
| Day 3 | 400 mg PO QID |
| Day 4 | 400 mg PO TID |
| Day 5 | 300 mg PO TID |
Step 2
CIWA-Ar < 8 for 8 h
→ Change assessments to every 4 h
Have benzodiazepines or opioids already been given?
No
10 mg/kg IBW
IV over 30 min
ED / ICU only
Yes
Individualize or defer loading
ED / ICU only
RASS ≤ 0
No dose
RASS +1 / +2
129.6 mg PO
or 130 mg IV
RASS +3 / +4
259.2 mg PO
or 260 mg IV
Assess RASS q1h until control
If at goal × 3 assessments → q4h RASS
Adjuncts × 5 days: thiamine 100 mg + folic acid 1 mg + multivitamin
Safety screen
Screen allergy, porphyria, respiratory compromise, hepatic failure, and major drug interactions.
Count all phenobarbital doses.
All IV phenobarbital in ED / ICU
Continuous SpO₂ and cardiac monitoring.
Reassess each IV dose.
Hold and notify for respiratory depression, oversedation, or hypotension.
Threshold: any alcohol use in the last 30 days, or a positive blood alcohol level on admission? If yes, score the items below — 1 point each.
Patient interview
Clinical evidence
Maximum 10. Score ≥ 4 → high risk for complicated withdrawal → phenobarbital pathway.
| +4 | Combative — Overtly combative, violent, immediate danger to staff |
|---|---|
| +3 | Very agitated — Pulls or removes tubes or catheters; aggressive |
| +2 | Agitated — Frequent non-purposeful movement; fights ventilator |
| +1 | Restless — Anxious, but movements not aggressive or vigorous |
| 0 | Alert and calm |
| −1 | Drowsy — Sustained awakening to voice, eye contact ≥ 10 s |
| −2 | Light sedation — Briefly awakens to voice, eye contact < 10 s |
| −3 | Moderate sedation — Movement or eye opening to voice, no eye contact |
| −4 | Deep sedation — No response to voice; moves or opens eyes to physical stimulation |
| −5 | Unarousable — No response to voice or physical stimulation |
Shaded rows are the phenobarbital re-dose bands.
Not validated for height under 5 ft.
