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

0

Mild nausea and no vomiting

+1

(More severe symptoms)

+2

(More severe symptoms)

+3

Intermittent nausea with dry heaves

+4

(More severe symptoms)

+5

(More severe symptoms)

+6

Constant nausea, frequent dry heaves and vomiting

+7

Tremor
Arms extended and fingers spread apart
No tremor

0

Not visible, but can be felt fingertip to fingertip

+1

(More severe symptoms)

+2

(More severe symptoms)

+3

Moderate, with patient’s arms extended

+4

(More severe symptoms)

+5

(More severe symptoms)

+6

Severe, even with arms not extended

+7

Paroxysmal sweats
No sweat visible

0

Barely perceptible sweating, palms moist

+1

(More severe symptoms)

+2

(More severe symptoms)

+3

Beads of sweat obvious on forehead

+4

(More severe symptoms)

+5

(More severe symptoms)

+6

Drenching sweats

+7

Anxiety
Ask, ‘Do you feel nervous?’
No anxiety, at ease

0

Mildly anxious

+1

(More severe symptoms)

+2

(More severe symptoms)

+3

Moderately anxious, or guarded, so anxiety is inferred

+4

(More severe symptoms)

+5

(More severe symptoms)

+6

Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

+7

Agitation
Normal activity

0

Somewhat more activity than normal activty

+1

(More severe symptoms)

+2

(More severe symptoms)

+3

Moderately fidgety and restless

+4

(More severe symptoms)

+5

(More severe symptoms)

+6

Paces back and forth during most of the interview, or constantly thrashes about

+7

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

0

Very mild itching, pin and needles, burning, or numbness

+1

Mild itching, pin and needles, burning, or numbness

+2

Moderate itching, pin and needles, burning, or numbness

+3

Moderately severe hallucinations

+4

Severe hallucinations

+5

Extremely severe hallucinations

+6

Continuous hallucinations

+7

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?’
Not present

0

Very mild harshness or ability or frighten

+1

Mild harshness or ability or frighten

+2

Moderate harshness or ability or frighten

+3

Moderately severe hallucinations

+4

Severe hallucinations

+5

Extremely severe hallucinations

+6

Continuous hallucinations

+7

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?’
Not present

0

Very mild sensitivity

+1

Mild sensitivity

+2

Moderate sensitivity

+3

Moderately severe hallucinations

+4

Severe hallucinations

+5

Extremely severe hallucinations

+6

Continuous hallucinations

+7

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.’
Not Present

0

Very mild

+1

Mild

+2

Moderate

+3

Moderately severe

+4

Severe

+5

Very severe

+6

Extremely severe

+7

Orientation/clouding of sensorium
Ask ‘What day is this? Where are you? Who am I?’
Oriented, can do serial additions

0

Can’t do serial additions or is uncertain about date

+1

Disoriented for date by no more than 2 calendar days

+2

Disoriented for date by more than 2 calendar days

+3

Disoriented to place or person

+4


				

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