CIWA-Ar for Alcohol Withdrawal
The CIWA-Ar objectifies severity of alcohol withdrawal.
When to Use
Pearls/Pitfalls
Why Use
No nausea and no vomiting
0Mild nausea and no vomiting
+1(More severe symptoms)
+2(More severe symptoms)
+3Intermittent nausea with dry heaves
+4(More severe symptoms)
+5(More severe symptoms)
+6Constant nausea, frequent dry heaves and vomiting
+7No tremor
0Not visible, but can be felt fingertip to fingertip
+1(More severe symptoms)
+2(More severe symptoms)
+3Moderate, with patient's arms extended
+4(More severe symptoms)
+5(More severe symptoms)
+6Severe, even with arms not extended
+7No sweat visible
0Barely perceptible sweating, palms moist
+1(More severe symptoms)
+2(More severe symptoms)
+3Beads of sweat obvious on forehead
+4(More severe symptoms)
+5(More severe symptoms)
+6Drenching sweats
+7No anxiety, at ease
0Mildly anxious
+1(More severe symptoms)
+2(More severe symptoms)
+3Moderately anxious, or guarded, so anxiety is inferred
+4(More severe symptoms)
+5(More severe symptoms)
+6Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions
+7Normal activity
0Somewhat more activity than normal activty
+1(More severe symptoms)
+2(More severe symptoms)
+3Moderately fidgety and restless
+4(More severe symptoms)
+5(More severe symptoms)
+6Paces back and forth during most of the interview, or constantly thrashes about
+7None
0Very mild itching, pin and needles, burning, or numbness
+1Mild itching, pin and needles, burning, or numbness
+2Moderate itching, pin and needles, burning, or numbness
+3Moderately severe hallucinations
+4Severe hallucinations
+5Extremely severe hallucinations
+6Continuous hallucinations
+7Not present
0Very mild harshness or ability to frighten
+1Mild harshness or ability to frighten
+2Moderate harshness or ability to frighten
+3Moderately severe hallucinations
+4Severe hallucinations
+5Extremely severe hallucinations
+6Continuous hallucinations
+7Not present
0Very mild sensitivity
+1Mild sensitivity
+2Moderate sensitivity
+3Moderately severe hallucinations
+4Severe hallucinations
+5Extremely severe hallucinations
+6Continuous hallucinations
+7Not Present
0Very mild
+1Mild
+2Moderate
+3Moderately severe
+4Severe
+5Very severe
+6Extremely severe
+7Oriented, can do serial additions
0Can't do serial additions or is uncertain about date
+1Disoriented for date by no more than 2 calendar days
+2Disoriented for date by more than 2 calendar days
+3Disoriented to place or person
+4Result:
Please fill out required fields.