This is an unprecedented time. It is the dedication of healthcare workers that will lead us through this crisis. Thank you for everything you do.

      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

    CIWA-Ar for Alcohol Withdrawal

    Objectifies alcohol withdrawal severity to help guide therapy.
    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
    Dr. Edward M. Sellers

    From the Creator

    Why did you develop the CIWA-Ar for Alcohol Withdrawal? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

    The CIWA-Ar is a shortened version of a previous 15 item scale CIWA (see Sullivan 1989). This program to improve recognition and treatment of alcohol withdrawal was conducted because of a lack of validated diagnostic and clinical monitoring tools that could guide and improve treatment.

    What pearls, pitfalls and/or tips do you have for users of the CIWA-Ar for Alcohol Withdrawal? Do you know of cases when it has been applied, interpreted, or used inappropriately?

    The CIWA-Ar has been translated into more than 20 different languages and is used very widely. There are some very good YouTube videos that are useful for training, such as this one. Almost 30 years after we published this paper, I still get approached about its implementation. The most common misinterpretation of the CIWA-Ar Score is that it is a recipe for when to use pharmacologic treatment. While scores of 10 or less rarely need pharmacologic treatment, clinical judgement is still very important with scores between 10-20. Our typical management has been to use diazePAM loading (Sellers 1983). With training, nursing staff can readily and reliably perform scoring, but the score should not be used to drive "standing orders".

    What recommendations do you have for doctors once they have applied the CIWA-Ar for Alcohol Withdrawal? Are there any adjustments or updates you would make to the score based on new data or practice changes?

    Our original paper still accurately outlines the reasons for using the CIWA-Ar and how to use it. We did not emphasize the importance of standardized training of all staff and the usefulness of the assessment of within and between rater reliability in the paper. Patients or standardized trained patients can be used to ensure good staff agreements on ratings.

    Management of patients today is potentially more complicated than it was when the CIWA-Ar was developed because of a very high incidence of other drug abuse. Detailed histories, careful clinical examination, and urine drug screens can help sort out more complex patients.

    How do you use the CIWA-Ar for Alcohol Withdrawal in your own clinical practice? Can you give an example of a scenario in which you use it?

    The CIWA-Ar should used in all patients suspected of being at risk to have alcohol withdrawal. Because it takes only a minute or two to administer, the scale can be used as frequently (i.e., every 1-2 hours) and can be used early when alcohol withdrawal is viewed only as a clinical risk.

    Any other research in the pipeline that you’re particularly excited about?

    A number of studies have examined the use of various benzodiazepines other than diazePAM for treating alcohol withdrawal. Once dosing adjustments are made for differences in potency and duration of effect, one would expect most could be effective as long as patients are carefully observed to avoid under- or excessive dosing.

    About the Creator

    Edward M. Sellers, MD, PhD, FRCPC, FACP, is the president and principal of DL Global Partners Inc., which specializes in clinical psychopharmacology and pharmacogenetics for substance abuse. He is also professor emeritus at the University of Toronto and helped establish its clinical psychopharmacology unit. Dr. Sellers has received several awards for his research in pharmacology and drug dependence, including the Rawls-Palmer Award given by the ASCPT.

    To view Dr. Edward M. Sellers's publications, visit PubMed

    About the Creator
    Dr. Edward M. Sellers