Ask: 'Do you feel sick to your stomach? Have you vomited?' (0 = no nausea, 7 = constant nausea/vomiting)
Arms extended, fingers spread. (0 = no tremor, 7 = severe, even with arms not extended)
(0 = no sweat, 7 = drenching sweats)
Ask: 'Do you feel nervous?' (0 = at ease, 7 = acute panic)
(0 = normal activity, 7 = paces/restless, thrashes)
Ask: 'Any itching, pins and needles, burning, numbness, bugs crawling?' (0 = none, 7 = continuous hallucinations)
Ask: 'Are you more aware of sounds? Are they harsh? Do they frighten you? Are you hearing things?' (0 = not present, 7 = continuous hallucinations)
Ask: 'Does the light hurt your eyes? Are you seeing anything that disturbs you? Are you seeing things you know aren't there?' (0 = not present, 7 = continuous hallucinations)
Ask: 'Does your head feel different? Does it hurt?' (0 = not present, 7 = extremely severe)
Ask: 'What day is this? Where are you? Who am I?' (0 = oriented, 4 = disoriented for place/person)
CIWA Score for Alcohol Withdrawal
The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) is a validated tool to quantify the severity of alcohol withdrawal and guide management. It consists of 10 items, each scored 0–7 (except orientation, 0–4). The total score helps determine the need for pharmacologic intervention and monitoring.
CIWA-Ar Items and Scoring
- Nausea and Vomiting: 0 = none, 7 = constant nausea/vomiting
- Tremor: 0 = none, 7 = severe, even with arms not extended
- Sweats: 0 = none, 7 = drenching sweats
- Anxiety: 0 = none, 7 = acute panic
- Agitation: 0 = normal, 7 = paces constantly
- Tactile Disturbances: 0 = none, 7 = continuous hallucinations
- Auditory Disturbances: 0 = none, 7 = continuous hallucinations
- Visual Disturbances: 0 = none, 7 = continuous hallucinations
- Headache: 0 = none, 7 = extremely severe
- Orientation/Clouding of Sensorium: 0 = oriented, 4 = disoriented
Total Score: Sum of all items (max 67).
Score Interpretation
- 0–8: Mild withdrawal (usually no medication needed)
- 9–15: Moderate withdrawal (consider medication)
- ≥16: Severe withdrawal (risk of delirium tremens/seizures; requires close monitoring and treatment)
Clinical Applications
- Assess at regular intervals (e.g., every 1–2 hours)
- Use in adults only; not validated for children or pregnant women
- Always consider clinical context and comorbidities
- Guide pharmacologic therapy (benzodiazepines, anticonvulsants)
- Determine level of monitoring required
References
- Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br J Addict. 1989;84(11):1353-1357.
- Bayard M, McIntyre J, Hill KR, Woodside J Jr. Alcohol withdrawal syndrome. Am Fam Physician. 2004;69(6):1443-1450.
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