Treatment
Mild (CIWA-Ar <8)
- Discharge with outpatient follow up.
- Provide tapering dose of long acting benzodiazepine like Chlordiazepoxide (Librium)
- 50-100 mg every 6 hours x 4 doses, then 25-50 mg every 6 hours for 2-3 days, then stop.
Moderate (CIWA-Ar 9-19)
- Administer IV or Oral benzodiazepines then reassess over 1-2 hours.
- Lorazepam 2-4 mg IV or PO
- Diazepam 10-20 mg IV or PO
- Chlordiazepoxide 50-100 mg PO
- If CIWA-Ar improves to <8, discharge with taper
- If CIWA-Ar remains 9-19, admit to monitored bed.
- If CIWA-AR increase to >20, see below
Severe (CIWA-Ar >20)
- Administer IV benzodiazepines every 10-15 minutes and reassess
- Diazepam 20 mg IV (up to 100mg IV per dose)
- Lorazepam 4 mg IV (up to 16 mg IV per dose)
- If CIWA-Ar remains >20, admit to ICU.
- Consider phenobarbital 10mg/kg IV
- Consider ketamine 0.3 mg/kg IV bolus + 0.3 mg/kg/hr infusion
- If CIWA-Ar improves to <20, see moderate and mild above.
The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-AR) is the most studied and widely use assessment for acute alcohol withdrawal. Many hospitals incorporate the revised short form below into their protocols. Typically, protocols rate patients by placing them into mild (<8), moderate (9-19) and severe (>20) categories.
Below is a description of the CIWA-AR scale as well as a summary of the interpretation and recommended treatment by category. For a more detailed description of alcohol withdrawal syndrome and its treatment, see the March 2021 issue of EMP – Alcohol Withdrawal Syndrome: Improving Outcomes in the Emergency Department With Aggressive Management Strategies
NAUSEA AND VOMITING
Ask “Do you feel sick to your stomach? Have you vomited?”
| 0 | No nausea and no vomiting |
| 1 | Mild nausea with no vomiting |
| 2 | (Increasing severity of symptoms) |
| 3 | (Increasing severity of symptoms) |
| 4 | Intermittent nausea with dry heaves |
| 5 | (Increasing severity of symptoms) |
| 6 | (Increasing severity of symptoms) |
| 7 | Constant nausea, frequent dry heaves and vomiting |
TREMOR
Arms extended and fingers spread apart.
| 0 | No tremor |
| 1 | Not visible, but can be felt fingertip to fingertip |
| 2 | (Increasing severity of symptoms) |
| 3 | (Increasing severity of symptoms) |
| 4 | Moderate with patient’s arms extended |
| 5 | (Increasing severity of symptoms) |
| 6 | (Increasing severity of symptoms) |
| 7 | Severe, even with arms not extended |
PAROXYSMAL SWEATS
| 0 | No sweat visible |
| 1 | Barely perceptible sweating, palms moist |
| 2 | (Increasing severity of symptoms) |
| 3 | (Increasing severity of symptoms) |
| 4 | Beads of sweat obvious on forehead |
| 5 | (Increasing severity of symptoms) |
| 6 | (Increasing severity of symptoms) |
| 7 | Drenching sweat |
ANXIETY
Ask “Do you feel nervous?”
| 0 | No anxiety, at east |
| 1 | Mildly anxious |
| 2 | (Increasing severity of symptoms) |
| 3 | (Increasing severity of symptoms) |
| 4 | Moderately anxious, or guarded, so anxiety is inferred |
| 5 | (Increasing severity of symptoms) |
| 6 | (Increasing severity of symptoms) |
| 7 | Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions |
AGITATION
| 0 | Normal activity |
| 1 | Somewhat more than normal activity |
| 2 | (Increasing severity of symptoms) |
| 3 | (Increasing severity of symptoms) |
| 4 | Moderately fidgety and restless |
| 5 | (Increasing severity of symptoms) |
| 6 | (Increasing severity of symptoms) |
| 7 | Paces back and forth during most of the interview, or constantly thrashes about |
TACTILE DISTURBANCES
Ask “Do you have any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?”
| 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?”
| 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?”
| 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 serial additions |
| 1 | Cannot do serial 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 |
Interpretation
| Total | Withdrawal Level |
|---|---|
| ≤8 | No or minimal withdrawal |
| 9-19 | Mild to moderate withdrawal |
| ≥20 | Severe withdrawal |
Further Reading
Alcohol Withdrawal Syndrome: Improving Outcomes in the Emergency Department With Aggressive Management Strategies – Pharmacology EXTRA Supplement – (Pharmacology CME) Date Release: Mar 2021. This Pharmacology EXTRA CME supplement (free to Emergency Medicine Practice subscribers) reviews the management of alcohol withdrawal syndrome.
References
- Tanya J, et al., Alcohol Withdrawal Syndrome, Emergency Medicine Practice, March, 2021, EB Medicine
- Addiction Medicine Essentials, Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar), Jan-Feb, 2001
- Long D, Long B, Koyfman A. The emergency medicine management of severe alcohol withdrawal. Am J Emerg Med. 2017 Jul;35(7):1005-1011. doi: 10.1016/j.ajem.2017.02.002. Epub 2017 Feb 4. PubMed
- MD Calc CIWA-Ar
Last Updated on January 24, 2023
Sam Ashoo, MD, FACEP, is board certified in emergency medicine and clinical informatics. He serves as EB Medicine’s editor-in-chief of interactive clinical pathways and FOAMEd blog, and host of EB Medicine’s EMplify podcast. Follow him below for more…
