CIWA-Ar for Alcohol Withdrawal
https://www.mdcalc.com/ciwa-ar-alcohol-withdrawal
When to 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.
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) Scale , Special Instructions:
- SCORE less than or equal to 7: Reassess every 1 hour X 2, then every 2 hours X 2, then every 4 hours X 24. If score less than or equal to 7 for 24 hours, change assessments to every 6 hours.
- SCORE 8-16: Reassess every 1 hour
- SCORE greater than or equal to 17: Reassess every 30 minutes
- Notify Physician if score greater than or equal to 17 for 4 consecutive hours. If patient mechanically ventilated, discontinue CIWA-Ar assessment order.
LORazepam. – known as ATIVAN Give 1 to 4 mg by mouth every dose per Protocol PRN for anxiety/agitation Nurse Instructions: CIWA-Ar Assessment Assessment and dosing as directed below:
CIWA-Ar score |
Dose |
< 7 |
No Med's required; Reassess every 1 hr x 2, then every 2 hrs x 2 then every 4 hrs for 24 hrs |
8-10 |
1 mg; Reassess every 1 hour |
11-13 |
2 mg; Reassess every 1 hour |
14-16 |
3 mg: Reassess every 1 hour |
> 17 |
4 mg; Reassess every 30 minutes |
May give IV or IM if unable to take PO |
|
Nausea/vomiting. Ask 'Do you feel sick to your stomach? Have you vomited?'
No nausea and no vomiting
Mild nausea and no vomiting
(More severe symptoms)
(More severe symptoms)
Intermittent nausea with dry heaves
(More severe symptoms)
(More severe symptoms)
Constant nausea, frequent dry heaves and vomiting
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?’
None
Very mild itching, pin and needles, burning, or numbness
Mild itching, pin and needles, burning, or numbness
Moderate itching, pin and needles, burning, or numbness
Moderately severe hallucinations
Severe hallucinations
Extremely severe hallucinations
Continuous 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?’
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?’