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Alcohol Withdrawal

Clinical Institute Withdrawal Assessment fo Alcohol Scale, Revised (CIWA-AR) is the most studied and widely use assessment for acute alcohol withdrawal. Many hospitals incorporate the revised short form below into their protocols. Typically, protocols rate patients by placing them into mild (<8), moderate (9-19) and severe (>20) categories.


NAUSEA AND VOMITING

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

0No nausea and no vomiting
1Mild nausea with no vomiting
2
3
4Intermittent nausea with dry heaves
5
6
7Constant nausea, frequent dry heaves and vomiting

TREMOR

Arms extended and fingers spread apart.

0No tremor
1Not visible, but can be felt fingertip to fingertip
2
3
4Moderate with patient’s arms extended
5
6
7Severe, even with arms not extended

PAROXYSMAL SWEATS

0No sweat visible
1Barely perceptible sweating, palms moist
2
3
4Beads of sweat obvious on forehead
5
6
7Drenching sweat

ANXIETY

Ask “Do you feel nervous?”

0No anxiety, at east
1Mildly anxious
2
3
4Moderately anxious, or guarded, so anxiety is inferred
5
6
7Equivalent to acute panic states as seen in severe delerium or acute schizophrenic reactions

AGITATION

0Normal activity
1Somewhat more than normal activity
2
3
4Moderately fidgety and restless
5
6
7Paces back and forth during most of the interview, or constantly thrashes about

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?”

0None
1Very mild itching, pins and needles, burning or numbness
2Mild itching, pins and needles, burning or numbness
3Moderate itching, pins and needles, burning or numbness
4Moderately severe hallucinations
5Severe hallucinations
6Extremely severe hallucinations
7Continuous hallucinations

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?”

0Not present
1Very mild harshness or ability to frighten
2Mild harshness or ability to frighten
3Moderate harshness or ability to frighten
4Moderately severe hallucinations
5Severe hallucinations
6Extremely severe hallucinations
7Continuous hallucinations

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?”

0Not present
1Very mild sensitivity
2Mild sensitivity
3Moderate sensitivity
4Moderately severe hallucinations
5Severe hallucinations
6Extremely severe hallucinations
7Continuous hallucinations

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.

0Not present
1Very mild
2Mild
3Moderate
4Moderately severe
5Severe
6Very severe
7Extremely Severe

ORIENTATION AND CLOUDING OF SENSORIUM

Ask “What day is this? Where are you? Who am I?”

0Oriented and can do serial additions
1Cannot do serial additions or is uncertain about date
2Disoriented for date by no more than 2 calendar days
3Disoriented for date by more than 2 calendar days
4Disoriented for place/or person

Interpretation

TotalWithdrawal Level
≤8No or minimal withdrawal
9-19Mild to moderate withdrawal
≥20Severe withdrawal

Treatment

Mild (CIWA-Ar <8)

  • Discharge with outpatient follow up.
  • Provide tapering dose of long acting benzodiazepine like Chlordiazepoxide (Librium)
    • 50-100 mg every 6 hours x 4 doses, then 25-50 mg every 6 hours for 2-3 days, then stop.

Moderate (CIWA-Ar 9-19)

  • Administer IV or Oral benzodiazepines then reassess over 1-2 hours.
    • Lorazepam 2-4 mg IV or PO
    • Diazepam 10-20 mg IV or PO
    • Chlordiazepoxide 50-100 mg PO
  • If CIWA-Ar improves to <8, discharge with taper
  • If CIWA-Ar remains 9-19, admit to monitored bed.
  • If CIWA-AR increase to >20, see below

Severe (CIWA-Ar >20)

  • Administer IV benzodiazepines every 10-15 minutes and reassess
    • Diazepam 20 mg IV (up to 100mg IV per dose)
    • Lorazepam 4 mg IV (up to 16 mg IV per dose)
  • If CIWA-Ar remains >20, admit to ICU.
    • Consider phenobarbital 10mg/kg IV
    • Consider ketamine 0.3 mg/kg IV bolus + 0.3 mg/kg/hr infusion
  • If CIWA-Ar improves to <20, see moderate and mild above.

References

  • Addiction Medicine Essentials, Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar), Jan-Feb, 2001, https://www.ci2i.research.va.gov/paws/pdfs/ciwa-ar.pdf
  • Long D, Long B, Koyfman A. The emergency medicine management of severe alcohol withdrawal. Am J Emerg Med. 2017 Jul;35(7):1005-1011. doi: 10.1016/j.ajem.2017.02.002. Epub 2017 Feb 4. PMID: 28188055.
  • Tanya J, et al., Alcohol Withdrawal Syndrome, Emergency Medicine Practice, March, 2021, EB Medicine
  • MD Calc CIWA-Ar

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