CIWA-Ar Explained

CIWA-Ar is an acronym that stands for clinical institute withdrawal assessment (revised version) for alcohol. It is a tool used to measure withdrawal symptoms for patients who are typically dependent on alcohol. The assessment is often done every four hours while the patient is stable, but more often if the patient starts to show withdrawal symptoms.

To use this tool, simply use the 10 question scale below. Observe the patient or ask the questions listed below and correlate the answer with its number. Add up all 10 of the numbers and the total determines whether further action should be taken. Use the calculator below as needed.

Click here to download and print this chart (pdf)

N/V  Tremor  Sweats  Anxiety  Agitation  Tactile  Auditory  Visual  Headache  Orientation  Total  Intervention

Nausea and Vomiting (N/V)

Ask "Do you feel sick to your stomach? Have you vomited?" Also done by observation.

0  No nausea and no vomiting

1  Mild nausea with no vomiting

4  Intermittent nausea with dry heaves

7  Constant nausea, frequent dry heaves and vomiting

Tremor

Have the patient's arms extended and fingers spread apart. Also done by observation.

0  No tremor

1  Not visible, but can be felt fingertip to fingertip

4  Moderate, with arms extended

7  Severe, even with arms not extended

Paroxysmal Sweats

Done by observation.

0  No sweat visible

1  Barely perceptible sweating, palms moist

4  Beads of sweat obvious on forehead

7  Drenching Sweats

Anxiety

Ask "Do you feel nervous?" Also done by observation.

0  No anxiety, at ease

1  Mildly anxious

4  Moderately anxious, or guarded, so anxiety is inferred

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

Agitation

Done by observation.

0  Normal activity

1  Somewhat more than normal activity

4  Moderately fidgety and restless

7  Paces 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?" Also done by observation.

0  None

1  Very mild itching, pins and needles, burning or numbness

2  Mild itching, pins and needles, burning or numbness

3  Moderate itching, pins and needles, burning or numbness

4  Moderately severe hallucinations

5  Severe hallucinations

6  Extremely Severe hallucinations

7  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?" Also done by observation.

0  Not present

1  Very mild harshness or ability to frighten

2  Mild harshness or ability to frighten

3  Moderate harshness or ability to frighten

4  Moderately severe hallucinations

5  Severe hallucinations

6  Extremely severe hallucinations

7  Continuous 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?" Also done by observation.

0  Not present

1  Very mild sensitivity

2  Mild sensitivity

3  Moderate sensitivity

4  Moderately severe hallucinations

5  Severe hallucinations

6  Extremely severe hallucinations

7  Continuous 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.

0  Not present

1  Very mild

2  Mild

3  Moderate

4  Moderately severe

5  Severe

6  Very severe

7  Extremely severe

Orientation and Clouding of Sensorium

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

0  Oriented and can do simple numerical additions (1+2=3)

1  Cannot do simple additions or is uncertain about date

2  Disoriented for date by no more than 2 calendar days

3  Disoriented for date by more than 2 calendar days

4  Disoriented for place/or person

Total Score

Less than or equal to 8 - absent or mild withdrawal

Between 9 and 19 - mild to moderate withdrawal

Greater than or equal to 20 - severe withdrawal

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powered by calculator.net

Intervention

The action taken after the CIWA-Ar score is calculated depends on the order. Typically the order is to give a medication that helps relax the patient. The hospital where I am employed typically gives lorazepam (Ativan) if the patient has a score of 8 or above. Other meds that may be given include diazepam (Valium) and chlordiazepoxide (Librium).

The IV dose is typically preferred because it works quicker than the oral dose. Also, It can be given when the patient isn't able to take pills due to the severity of the symptoms or if they have a nothing by mouth (NPO) order. After a dose is given, the patient is then reevaluated after 15 minutes to determine whether another dose is needed.

Medical References for Caregivers

From CIWA-Ar Explained to Home

Reference:

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 Nov;84(11):1353-7. PubMed PMID: 2597811.

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