Calc Function

    • Calcs that help predict probability of a diseaseDiagnosis
    • Subcategory of 'Diagnosis' designed to be very sensitiveRule Out
    • Disease is diagnosed: prognosticate to guide treatmentPrognosis
    • Numerical inputs and outputsFormula
    • Med treatment and moreTreatment
    • Suggested protocolsAlgorithm

    Disease

    Select...

    Specialty

    Select...

    Chief Complaint

    Select...

    Organ System

    Select...

    Patent Pending

    Save your unit preferences in settings!

    CIWA-Ar for Alcohol Withdrawal

    Objectifies alcohol withdrawal severity to help guide therapy.
    Favorite
    When to Use
    Pearls/Pitfalls
    Why Use

    Patients in a variety of settings, including outpatient, emergency, psychiatric, and general medical-surgical units, for whom there is clinical concern for alcohol withdrawal.

    • The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale has ten items, each evaluated independently then aggregated to yield a score correlating with severity of alcohol withdrawal.
    • There is no absolute relationship between alcohol use pattern and risk of physiologic dependence or withdrawal for a given individual. In general, any suspicion of daily alcohol use over several weeks or more, regardless of quantity, should raise concern for potential alcohol withdrawal.
    • Cannot be used effectively in intubated/sedated patients. A sedation scale such as the Richmond Agitation-Sedation Scale (RASS) is more appropriate in this setting.
    • Additional variables that may contribute to risk include age, medical comorbidities like hepatic dysfunction, concomitant medication use, and low seizure threshold. (Roffman JL 2006)
    • The CIWA-Ar provides an efficient (<5 mins) and objective means of assessing alcohol withdrawal that can then be utilized in treatment protocols.
    • Patients frequently under-report alcohol use and physicians often overlook alcohol problems in patients. (Kitchens JM 1994) It is estimated that 1 of every 5 patients admitted to a hospital abuses alcohol. (Schuckit 2001)
    • Unrecognized alcohol withdrawal can lead to potentially life-threatening consequences including seizures and delirium tremens.
    No nausea and no vomiting
    0
    Mild nausea and no vomiting
    +1
    (More severe symptoms)
    +2
    (More severe symptoms)
    +3
    Intermittent nausea with dry heaves
    +4
    (More severe symptoms)
    +5
    (More severe symptoms)
    +6
    Constant nausea, frequent dry heaves and vomiting
    +7
    No tremor
    0
    Not visible, but can be felt fingertip to fingertip
    +1
    (More severe symptoms)
    +2
    (More severe symptoms)
    +3
    Moderate, with patient's arms extended
    +4
    (More severe symptoms)
    +5
    (More severe symptoms)
    +6
    Severe, even with arms not extended
    +7
    No sweat visible
    0
    Barely perceptible sweating, palms moist
    +1
    (More severe symptoms)
    +2
    (More severe symptoms)
    +3
    Beads of sweat obvious on forehead
    +4
    (More severe symptoms)
    +5
    (More severe symptoms)
    +6
    Drenching sweats
    +7
    No anxiety, at ease
    0
    Mildly anxious
    +1
    (More severe symptoms)
    +2
    (More severe symptoms)
    +3
    Moderately anxious, or guarded, so anxiety is inferred
    +4
    (More severe symptoms)
    +5
    (More severe symptoms)
    +6
    Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions
    +7
    Normal activity
    0
    Somewhat more activity than normal activty
    +1
    (More severe symptoms)
    +2
    (More severe symptoms)
    +3
    Moderately fidgety and restless
    +4
    (More severe symptoms)
    +5
    (More severe symptoms)
    +6
    Paces back and forth during most of the interview, or constantly thrashes about
    +7
    None
    0
    Very mild itching, pin and needles, burning, or numbness
    +1
    Mild itching, pin and needles, burning, or numbness
    +2
    Moderate itching, pin and needles, burning, or numbness
    +3
    Moderately severe hallucinations
    +4
    Severe hallucinations
    +5
    Extremely severe hallucinations
    +6
    Continuous hallucinations
    +7
    Not present
    0
    Very mild harshness or ability or frighten
    +1
    Mild harshness or ability or frighten
    +2
    Moderate harshness or ability or frighten
    +3
    Moderately severe hallucinations
    +4
    Severe hallucinations
    +5
    Extremely severe hallucinations
    +6
    Continuous hallucinations
    +7
    Not present
    0
    Very mild sensitivity
    +1
    Mild sensitivity
    +2
    Moderate sensitivity
    +3
    Moderately severe hallucinations
    +4
    Severe hallucinations
    +5
    Extremely severe hallucinations
    +6
    Continuous hallucinations
    +7
    Not Present
    0
    Very mild
    +1
    Mild
    +2
    Moderate
    +3
    Moderately severe
    +4
    Severe
    +5
    Very severe
    +6
    Extremely severe
    +7
    Oriented, can do serial additions
    0
    Can't do serial additions or is uncertain about date
    +1
    Disoriented for date by no more than 2 calendar days
    +2
    Disoriented for date by more than 2 calendar days
    +3
    Disoriented to place or person
    +4

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Advice

    • Benzodiazepines are generally used to control psychomotor agitation and prevent progression to more severe withdrawal.
    • Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) are the most frequently used benzodiazepines. Follow your hospital's own alcohol withdrawal protocol; frequently treatment begins with benzodiazepines when CIWA-Ar scores reach 8-10, with standing or as needed dosing for scores 10-20. Some protocols even include transfer to the ICU for scores >20.
    • Consider additional supportive care, including intravenous fluids, nutritional supplementation, and frequent clinical reassessment including vital signs.

    Management

    Assessment protocols utilizing CIWA-Ar vary and include medication dosing triggered by symptoms only and combined symptom-triggered + fixed-dose medication dosing.

    Critical Actions

    Other conditions can mimic or coexist with alcohol withdrawal, including:

    • Drug overdose
    • Trauma (eg, intracranial hemorrhage)
    • Infection (eg, meningitis)
    • Metabolic derangements
    • Hepatic failure
    • Gastrointestinal bleeding

    Consider additional testing to rule out alternative diagnoses, especially if presentation includes altered mental status and/or fever.

    About the Creator
    Dr. Edward M. Sellers
    Are you Dr. Edward M. Sellers?