CIWA-Ar

Monitors severity of alcohol withdrawal to guide benzodiazepine dosing

Indication

Monitors severity of alcohol withdrawal to guide benzodiazepine dosing

Criteria

id: nausea; label: Nausea/vomiting; type: options; options: label: None; value: 0; label: Mild nausea, no vomiting; value: 2; label: Intermittent nausea with dry heaves; value: 4; label: Constant nausea, frequent dry heaves and vomiting; value: 7
id: tremor; label: Tremor; type: options; options: label: No tremor; value: 0; label: Not visible, can be felt fingertip to fingertip; value: 2; label: Moderate, with arms extended; value: 4; label: Severe, even with arms not extended; value: 7
id: sweating; label: Paroxysmal sweats; type: options; options: label: No sweating; value: 0; label: Barely perceptible sweating, moist palms; value: 2; label: Beads of sweat on forehead; value: 4; label: Drenching sweats; value: 7
id: anxiety; label: Anxiety; type: options; options: label: No anxiety, at ease; value: 0; label: Mildly anxious; value: 2; label: Moderately anxious; value: 4; label: Equivalent to acute panic; value: 7
id: agitation; label: Agitation; type: options; options: label: Normal activity; value: 0; label: Somewhat more than normal activity; value: 2; label: Moderately fidgety and restless; value: 4; label: Paces back and forth or constantly thrashes about; value: 7
id: tactile; label: Tactile disturbances; type: options; options: label: None; value: 0; label: Mild itching, pins and needles, burning, numbness; value: 2; label: Moderate hallucinations; value: 4; label: Severe hallucinations or illusions; value: 7
id: auditory; label: Auditory disturbances; type: options; options: label: None; value: 0; label: Mild harshness or ability to frighten; value: 2; label: Moderate hallucinations; value: 4; label: Severe auditory hallucinations; value: 7
id: visual; label: Visual disturbances; type: options; options: label: None; value: 0; label: Mild sensitivity; value: 2; label: Moderate visual hallucinations; value: 4; label: Severe visual hallucinations; value: 7
id: headache; label: Headache, fullness in head; type: options; options: label: Not present; value: 0; label: Very mild; value: 2; label: Moderately severe; value: 4; label: Extremely severe; value: 7
id: orientation; label: Orientation and clouding; type: options; options: label: Oriented and can do serial additions; value: 0; label: Uncertain about date; value: 2; label: Date uncertain by more than 2 days; value: 4

Interpretation

function(score) { if (score <= 8) return { risk: score + '/67', tier: 'Mild Withdrawal', action: 'Symptom management. No benzodiazepines needed. Reassess q4-8h. Thiamine, folate, fluids.', color: 'green' }; if (score <= 15) return { risk: score + '/67', tier: 'Moderate Withdrawal', action: 'Consider benzodiazepines. Chlordiazepoxide 25-50mg or lorazepam 1-2mg. Reassess q1-2h.', color: 'yellow' }; if (score <= 20) return { risk: score + '/67', tier: 'Severe Withdrawal', action: 'Benzodiazepines indicated. Chlordiazepoxide 50-100mg or lorazepam 2-4mg. Reassess q1h. Monitor for seizures.', color: 'red' }; return { risk: score + '/67', tier: 'Very Severe / DTs Risk', action: 'High-dose benzodiazepines. Consider ICU admission. Watch for seizures, delirium tremens. Phenobarbital if refractory. 1:1 observation.', color: 'red' }; }

Clinical pearls

Symptom-triggered protocol (treat CIWA >8) uses 50% less benzodiazepines than fixed-schedule dosing
Alcohol withdrawal seizures typically occur 12-48 hours after last drink
Delirium tremens peaks at 48-72 hours — mortality 5-15% if untreated
Always give thiamine BEFORE glucose to prevent Wernicke encephalopathy

Source and review

Sullivan et al., Br J Addict 1989. Last reviewed: 2024-11-01