CIWA-Ar for Alcohol Withdrawal Calculator

How does this CIWA-Ar for alcohol withdrawal calculator work?

This health tool evaluates alcohol related symptoms and whether the subject has developed AWS – alcohol withdrawal syndrome based on the Clinical Institute Withdrawal Assessment for Alcohol revised scale.

This CIWA-Ar for alcohol withdrawal calculator contains 10 questions with different answer choices, all weighing from 0 to 7 points. The assessor focuses on the following criteria in the standardized assessment scale and uses questions such as the ones employed below to observe and evaluate the subject’s condition and severity. It is also used to monitor therapy and to avoid under or over medication with benzodiazepines in patients with alcohol withdrawal.

■ Nausea/vomiting – Do you feel sick to your stomach? Have you vomited? Questions then followed by a discussion about related symptoms and frequency.

■ Tremor – observing the tremor status, in relaxed position but also with arms extended and fingers spread apart.

■ Paroxysmal sweats – observing the degree of sweating, amount, localization and trigger factors such as lowered blood alcohol content.

■ Headache/sensation of fullness in head – questions such as Does your head feel different? Does it feel like there is a band around your head? The assessor note is that dizziness or lightheadedness should not be taken in consideration at this stage and only head ache severity should be counted.

■ Orientation/clouding of sensorium – with questions about timing, people recognition and surrounding environment such as What day is this? Where are you? Who am I?

■ Anxiety – concerns the general degree of nervousness and the display of anxious signs.

■ Agitation – display of restlessness, fidgeting and the frequency.

■ Visual disturbances – 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?

■ Tactile disturbances – assessing tactile sensations and hallucinations: Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?

■ Auditory disturbances – focuses on auditory sensations, changes in perception: 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?

Usually the score comes with a Withdrawal Assessment Sheet or the clinician can start one on their own and also state the vitals (expecting a slight derangement from normal in them as well) and the administration of medication schedule. The CIWA-Ar should also be repeated and reassessed the symptoms in 30 to 60 minutes from the moment medication has been administered.

Only criticism is that CIWA-Ar scale cannot be used with patients with other dependencies beside alcohol, in patients with severe liver conditions or those with whom communication is impaired and cannot report the symptoms.

Alcohol withdrawal syndrome AWS

Symptoms of withdrawal appear within 6 to 24 hours from the last drink, are less common or of less intensity in subjects aged below 30 but likely in people with developed alcoholism, who drink more than 8 drinks per day, every day in the past 2 weeks and commonly include:

■ Nausea;

■ Sweats;

■ Tremor;

■ Lack of appetite;

■ Headaches;

■ Diarrhea;

■ Restlessness;

■ Hallucinations;

■ Elevated blood pressure;

■ Seizures (in more complex cases or within 72 hours from last drink – generalized tonic clonic seizures);

■ Confusion;

■ Delirium tremens (worsening symptoms) – hallucinations, disorientation, tachycardia, fever, diaphoresis, hypertension.

Acute alcohol withdrawal protocol with CIWA-Ar interpretation

Score interpretation is as follows:

■ 0 – 9 points: Absent or minimal withdrawal;

■ 10 – 15 points: Mild withdrawal;

■ 16 – 20 points: Moderate withdrawal;

■ 21 – 67 points: Severe withdrawal.

For scores above 8, early intervention with prophylactic medication can help with the prevention of withdrawal symptoms. For scores above 15, if medication has already been started, additional PRN therapy should be implemented as well. Some of the scores above 21 should also be taken in consideration for hospitalization, depending on individual cases when management as outpatient is not possible.

The first hand protocol involves the patient being given the fixed dose of detox treatment with a Benzodiazepine (Diazepam 20 mg).  Benzodiazepines are election choice because of their long half life. This is standard and is repeated every 90 minutes until the clinician assesses that there are no more withdrawal symptoms present and no blood alcohol concentration.

Symptom triggered regime management advises: Diazepam 10-20 mg orally stat if score above 8.

Continue to assess CIWA-Ar every: 4 hours if score below 8, 2 hours if score 8-19, or 1 hour if score 20 or more. Continuing with diazepam 10-20 mg orally every 2 hours if CIWA-Ar > 8 for 3 doses.

Withdrawal seizure prophylaxis involves:

■ Day 0: Diazepam 20 mg two hourly by weight to 80 mg if < 90 kg and 100 mg if 90 kg;

■ Day 1, 2: Diazepam 10 mg orally BD;

■ Day 3: Diazepam 5 mg orally BD.

References

1) Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. (1989) Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict; 84(11):1353-7.

2) Bakhla AK, Khess CR, Verma V, Hembram M, Praharaj SK, Soren S. (2014) Factor Structure of CIWA-Ar in Alcohol Withdrawal. J Addict; 2014:745839.

3) Wartenberg AA, Nirenberg TD, Liepman MR, Silvia LY, Begin AM, Monti PM. (1990) Detoxification of alcoholics: improving care by symptom-triggered sedation. Alcohol Clin Exp Res; 14(1):71-5.

4) Nuss MA, Elnicki DM, Dunsworth TS, Makela EH. (2004) Utilizing CIWA-Ar to assess use of benzodiazepines in patients vulnerable to alcohol withdrawal syndrome. W V Med J; 100(1):21-5.