Toxicology / Acute Medicine

CIWA-Ar Alcohol Withdrawal Scale

Clinical Institute Withdrawal Assessment for Alcohol, Revised. 10-item bedside assessment for severity of alcohol withdrawal with treatment guidance.

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CIWA-Ar Total0/10 scored

Nausea and Vomiting

“Do you feel sick to your stomach? Have you vomited?”

Observe the patient for nausea and vomiting.

0 = No nausea, no vomiting

1 = Mild nausea with no vomiting

4 = Intermittent nausea with dry heaves

7 = Constant nausea, frequent dry heaves and vomiting

Tremor

“Arms extended and fingers spread apart. Observe tremor.”

Ask patient to extend arms with fingers spread apart. Observe for 5-10 seconds.

0 = No tremor

1 = Not visible, but can be felt fingertip to fingertip

4 = Moderate, with arms extended

7 = Severe, even with arms not extended

Paroxysmal Sweats

“Do you feel sweaty? (Observation)”

Observe for sweating. Feel the palms.

0 = No sweat visible

1 = Barely perceptible sweating, palms moist

4 = Beads of sweat obvious on forehead

7 = Drenching sweats

Anxiety

“Do you feel nervous? (Observation)”

Assess both subjective report and objective observation of anxiety.

0 = No anxiety, at ease

1 = Mildly anxious

4 = Moderately anxious, or guarded

7 = Equivalent to acute panic states

Agitation

“Observe the patient’s activity level.”

Observe general activity and restlessness throughout assessment.

0 = Normal activity

1 = Somewhat more than normal activity

4 = Moderately fidgety and restless

7 = Paces back and forth, constantly thrashes about

Tactile Disturbances

“Have you any itching, pins and needles, burning, or numbness? Do you feel bugs crawling on or under your skin?”

Ask about abnormal tactile sensations. Differentiate between mild sensory disturbances and frank hallucinations.

0 = None

1 = Very mild itching, pins and needles, burning or numbness

2 = Mild itching, pins and needles, burning or numbness

3 = Moderate itching, pins and needles, burning or numbness

4 = Moderately severe hallucinations

5 = Severe hallucinations

6 = Extremely severe hallucinations

7 = Continuous hallucinations

Auditory Disturbances

“Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?”

Ask about sound sensitivity and auditory hallucinations. Grade severity.

0 = Not present

1 = Very mild harshness or ability to frighten

2 = Mild harshness or ability to frighten

3 = Moderate harshness or ability to frighten

4 = Moderately severe hallucinations

5 = Severe hallucinations

6 = Extremely severe hallucinations

7 = Continuous hallucinations

Visual Disturbances

“Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?”

Ask about light sensitivity and visual hallucinations. Grade severity.

0 = Not present

1 = Very mild sensitivity

2 = Mild sensitivity

3 = Moderate sensitivity

4 = Moderately severe hallucinations

5 = Severe hallucinations

6 = Extremely severe hallucinations

7 = Continuous hallucinations

Headache, Fullness in Head

“Does your head feel different? Does it feel like there is a band around your head? (Do not rate for dizziness or lightheadedness.)”

Ask about headache and head fullness. Do not rate dizziness or lightheadedness.

0 = Not present

1 = Very mild headache

2 = Mild headache

3 = Moderate headache

4 = Moderately severe headache

5 = Severe headache

6 = Very severe headache

7 = Extremely severe headache

Orientation and Clouding of Sensorium

“What day is this? Where are you? Who am I? Can you do serial subtractions (100 - 7)?”

Assess orientation to date, place, and person. Test serial additions or subtractions.

0 = Oriented and can do serial additions

1 = Cannot do serial additions OR uncertain about date

2 = Disoriented for date by no more than 2 calendar days

3 = Disoriented for date by more than 2 calendar days

4 = Disoriented for place and/or person

Score Interpretation

0–9Absent or minimal withdrawalMay not need medication

10–18Mild to moderate withdrawalConsider medical management

19–67Severe withdrawalIntensive care, high risk of seizures/DT

Symptom-Triggered Treatment Guide

Score < 10Monitor + supportive care

Monitor CIWA-Ar every 4\u20138 hours
Thiamine, IV fluids, multivitamins
Reassess if symptoms escalate

Score 10\u201318Pharmacotherapy

Chlordiazepoxide 25\u201350 mg PO, or
Diazepam 10\u201320 mg PO/IV, or
Lorazepam 2\u20134 mg PO/IV
Repeat every hour until CIWA < 10

Score > 18Aggressive treatment / ICU

Lorazepam 2\u20134 mg IV every 15\u201320 min
Consider ICU admission
Phenobarbital if refractory (130\u2013260 mg IV)
Reassess CIWA every 1\u20132 hours

Based on Sullivan JT et al. Br J Addict 1989. Enhanced with clinical pearls by Dr Sumit Mandal.