CIWA-Ar
Alcohol Withdrawal Severity
<10 mild · 10-18 moderate · ≥19 severe. Protocols typically dose at ≥8-10.
On the AANP exam, alcohol withdrawal vignettes ask when to dose benzodiazepines and when to admit. CIWA-Ar grades severity across 10 items — nausea, tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation — each scored 0-7 except orientation (0-4). Under 10 is mild and may not need pharmacotherapy; 10-18 is moderate and triggers symptom-triggered dosing; 19 or higher is severe and warrants inpatient management. Most protocols dose at a CIWA threshold of 8-10. Symptom-triggered beats fixed-dose for outcomes, and benzodiazepines remain first-line. Phenobarbital and adjuncts come up in resistant or DT-prone cases.
- N/VNausea and vomiting (0-7)0 none → 7 constant with dry heaves.
- TremorTremor (0-7)0 none → 7 severe even with arms not extended.
- SweatsParoxysmal sweats (0-7)Visible moist palms → drenching sweats.
- AnxietyAnxiety (0-7)At ease → acute panic states.
- AgitationAgitation (0-7)Normal activity → pacing, thrashing.
- TactileTactile disturbances (0-7)Itching, pins-and-needles, bugs crawling on skin.
- AuditoryAuditory disturbances (0-7)Sensitivity to sound → continuous hallucinations.
- VisualVisual disturbances (0-7)Sensitivity to light → continuous hallucinations.
- HAHeadache / fullness in head (0-7)None → extremely severe.
- OrientationOrientation and clouding of sensorium (0-4)Oriented x4 → disoriented to place/person.
Clinical Context
Symptom-triggered benzodiazepine dosing based on CIWA-Ar is the standard for inpatient alcohol withdrawal — reduces total benzo exposure vs. fixed scheduled dosing. Reassess every 1-4 hours in active withdrawal.
Withdrawal timeline: 6-24h minor symptoms, 12-24h alcoholic hallucinosis (clear sensorium), 24-48h withdrawal seizures, 48-96h delirium tremens (10-15% untreated mortality). Give thiamine 100 mg IV BEFORE any glucose-containing fluid (prevents Wernicke). Add folate and multivitamin. Manage electrolytes aggressively — hypomagnesemia and hypokalemia are common.
Contraindications / limits of CIWA-Ar: can't use it in patients who can't communicate, are intoxicated, or have baseline dementia/psychosis (symptoms aren't interpretable). Those patients need fixed-dose prophylaxis or a different protocol.
Related Mnemonics
- CAGE — Alcohol Use Disorder Screening
- CRAFFT — Adolescent Substance Use Screen
- DIG FAST — Manic Episode Criteria (DSM-5)
- HEADSS — Adolescent Psychosocial Assessment
- SAD PERSONS — Suicide Risk Assessment
Sources
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