MDCalc

CIWA-Ar for Alcohol Withdrawal

The CIWA-Ar objectifies severity of alcohol withdrawal.

Nausea/vomiting
Ask 'Do you feel sick to your stomach? Have you vomited?'

Tremor

Arms extended and fingers spread apart

Paroxysmal sweats

Anxiety

Ask, 'Do you feel nervous?'

Agitation

Tactile disturbances
Ask, 'Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?'
Auditory disturbances
Ask, '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?'
Visual disturbances
Ask 'Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?'
Headache/fullness in head
Ask 'Does your head feel different? Does it feel like there is a band around your head?' Do not rate for dizziness or lightheadedness. Otherwise, rate 'severity.'
Orientation/clouding of sensorium
Ask 'What day is this? Where are you? Who am I?'

Result:

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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.

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