CIWA-Ar Alcohol Withdrawal Score
Interactive CIWA-Ar score with IAEM ED/CDU alcohol withdrawal pathway: symptom-triggered diazepam, Pabrinex, refractory AWS, and special populations.
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CIWA-Ar alcohol withdrawal score
10-item score — IAEM ED/CDU symptom-triggered diazepam pathway
1. Nausea / vomiting
Ask: 'Do you feel sick to your stomach? Have you vomited?'
2. Tremor
Arms extended and fingers spread apart.
3. Paroxysmal sweats
Observe for sweating.
4. Anxiety
Ask: 'Do you feel nervous?'
5. Agitation
Observe activity during the interview.
6. Tactile disturbances
Ask: 'Have you any itching, pins and needles, burning, numbness, or bugs crawling on/under your skin?'
7. Auditory disturbances
Ask: 'Are you more aware of sounds? Are they harsh? Do they frighten you? Hearing anything disturbing or that is not there?'
8. Visual disturbances
Ask: 'Does the light appear too bright? Colour different? Hurt your eyes? Seeing anything disturbing or that is not there?'
9. Headache / fullness in head
Ask: 'Does your head feel different? Like a band around your head?' Do not rate dizziness or lightheadedness.
10. Orientation / clouding of sensorium
Ask: 'What day is this? Where are you? Who am I?'
Educational aid only. Confirm local alcohol withdrawal protocol, benzodiazepine choice, and Pabrinex chart. Vital signs are recorded separately and not included in the total.
CIWA-Ar: 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. doi: 10.1111/j.1360-0443.1989.tb00737.x. PMID: 2597811.
🚨 Red Flags / Escalation
- Haemodynamic instability, DTs, Wernicke’s encephalopathy, or Korsakoff’s → not for CDU symptom-triggered treatment (STT); admit medically (IAEM).
- First seizure in AWS → CT brain. Recurrent withdrawal seizures: lorazepam / phenytoin IV per local protocol.
- Refractory agitation/seizures on oral diazepam → escalate scoring to 30–60 min, add PRN diazepam 20 mg PO, then lorazepam → senior / ICU / anaesthetics (see below).
- Drowsiness is not a feature of alcohol withdrawal — look for sepsis, hypoxia, hypoglycaemia, Na imbalance, over-sedation, MI, liver/renal failure, intracranial cause.
- CIWA-Ar >10 after 24 h of STT → reassess diagnosis (benzo dependency, drug-seeking, organic delirium, trauma); STT may continue only after senior review.
👥 Who this pathway covers (IAEM)
- STT means scoring CIWA-Ar regularly and giving benzodiazepine only when the score is above threshold — IAEM’s preferred ED/CDU approach (wards often use a fixed-dose regimen instead).
- Adults >16 years in ED/CDU with acute withdrawal (tremor, agitation, nausea/vomiting) and/or autonomic hyperactivity (sweating, tachycardia).
- Also: not yet withdrawing but high risk — drinking >10 units/day, previous withdrawal or DTs (Irish unit ≈ 10 g alcohol).
- Exclusion / use fixed-dose or inpatient pathways instead: age <16; dependency on other drugs as well as alcohol; severe liver impairment, respiratory failure, or other major physical illness; unable to communicate / give verbal consent; haemodynamically unstable; established DTs, Wernicke’s, or Korsakoff’s.
- History of benzodiazepine dependency → prefer fixed-dose chlordiazepoxide regimen (not STT diazepam) per IAEM.
🏥 CDU vs medical admission (IAEM)
- CDU STT suitable if: in ED; obvious withdrawal (tremor, agitation, CIWA-Ar >10, autonomic hyperactivity e.g. pulse >100) OR high-risk history as above — confirm local CDU criteria.
- Medical admission: haemodynamically unstable; unlikely fit for discharge within 24 h; complex medical/surgical problems (e.g. DKA, PUO); DTs / Wernicke’s / Korsakoff’s.
- eMed disposition tip: CIWA-Ar <10 usually no admission for withdrawal alone; 10–20 consider if first presentation, social vulnerability, prior seizures, significant liver disease; >20 admit medically and involve psychiatry early.
📋 CDU work-up (every patient on STT)
- Vitals + neurological observation every 90 minutes (recorded separately from CIWA-Ar).
- Bloods: FBC, U&E, LFTs, glucose; coagulation if liver disease suspected. Look for stigmata of chronic liver disease → consider gastroenterology/hepatology.
- CIWA-Ar every 90 minutes (30–60 min if severe / uncontrolled). Scoring takes <2 minutes and has high inter-rater reliability.
- STT detox complete after three consecutive CIWA-Ar scores <10; then informal monitoring for re-emergence.
📊 CIWA-Ar bands & diazepam (IAEM)
- Flowchart shortcut used in IAEM/eMed: CIWA-Ar >10 → diazepam 20 mg PO; CIWA-Ar <10 → no medication.
- Diazepam preferred for STT (rapid peak effect; long half-life smooths rebound). Equivalence: diazepam 10 mg ≈ chlordiazepoxide 25 mg ≈ lorazepam 1 mg.
- PRN breakthrough doses should match the usual treatment dose (diazepam 20 mg PO) and may be needed before the next 90-min review in severe withdrawal.
0–9
- Band
- Absent / minimal
- Action (IAEM CDU)
- No benzo; repeat CIWA-Ar in 90 min
10–19
- Band
- Mild–moderate
- Action (IAEM CDU)
- Diazepam 20 mg PO stat; repeat CIWA-Ar in 90 min
>20
- Band
- Severe
- Action (IAEM CDU)
- Diazepam 20 mg PO stat; repeat in 90 min (or every 30–60 min)
| CIWA-Ar | Band | Action (IAEM CDU) |
|---|---|---|
| 0–9 | Absent / minimal | No benzo; repeat CIWA-Ar in 90 min |
| 10–19 | Mild–moderate | Diazepam 20 mg PO stat; repeat CIWA-Ar in 90 min |
| >20 | Severe | Diazepam 20 mg PO stat; repeat in 90 min (or every 30–60 min) |
💊 Pabrinex / Wernicke’s (IAEM)
- All alcohol-dependent patients in ED/CDU: Pabrinex (ampoules 1 & 2) IV once daily for 3 days (or for the duration of stay) as prophylaxis.
- Signs of Wernicke’s (delirium, ataxia, gaze palsy): give IV thiamine before glucose if possible; therapeutic Pabrinex 2 pairs (1 & 2) TDS IV.
- Facilities for treating anaphylaxis should be available when giving IV Pabrinex. Continue oral thiamine after IV course per local guideline.
🔥 Uncontrolled / refractory AWS (IAEM)
- Increase CIWA-Ar monitoring to every 30–60 minutes + PRN diazepam 20 mg PO.
- Reconsider diagnosis: psychosis, infection, trauma (SDH/ICH), overdose, electrolyte disturbance, benzo dependency.
- Second line: lorazepam 2–4 mg PO/IV; repeat if required up to 2 doses at 30-minute intervals.
- Third line: haloperidol 0.5–5 mg PO/IM — caution: lowers seizure threshold; use ½ dose if age >75; contraindicated in long QT (baseline ECG).
- Extremely high benzo need + respiratory depression / airway compromise → senior help, ICU/anaesthetics; may need propofol infusion and intubation.
🧬 Special populations (IAEM)
Abnormal LFTs, no clinical liver failure (normal bilirubin, albumin, PT)
- Benzodiazepine advice
- May use chlordiazepoxide; monitor sedation
Moderate liver disease
- Benzodiazepine advice
- Half-dose diazepam/chlordiazepoxide, or prefer lorazepam (shorter half-life)
Decompensated liver disease
- Benzodiazepine advice
- Close monitoring; lorazepam preferred; watch over-sedation and encephalopathy
Elderly (>75, or >65 with frailty)
- Benzodiazepine advice
- Halve usual doses; lengthen intervals if needed; consider lorazepam
Pregnancy
- Benzodiazepine advice
- Inpatient under obstetrics + fetal monitoring; chlordiazepoxide often preferred (lower teratogenic risk); near term watch neonate for floppy baby / benzo withdrawal
| Population | Benzodiazepine advice |
|---|---|
| Abnormal LFTs, no clinical liver failure (normal bilirubin, albumin, PT) | May use chlordiazepoxide; monitor sedation |
| Moderate liver disease | Half-dose diazepam/chlordiazepoxide, or prefer lorazepam (shorter half-life) |
| Decompensated liver disease | Close monitoring; lorazepam preferred; watch over-sedation and encephalopathy |
| Elderly (>75, or >65 with frailty) | Halve usual doses; lengthen intervals if needed; consider lorazepam |
| Pregnancy | Inpatient under obstetrics + fetal monitoring; chlordiazepoxide often preferred (lower teratogenic risk); near term watch neonate for floppy baby / benzo withdrawal |
🔍 Screening context (IAEM)
- Screen ED attenders for alcohol misuse — AUDIT-C preferred over CAGE (higher sensitivity for hazardous/harmful drinking). Use the interactive AUDIT-C tool.
- Irish standard drink ≈ 10 g alcohol (e.g. ½ pint 3.5% beer, or 25 ml spirits). Hazardous/risky use (non-dependent): >7 drinks/week or >3/occasion (women); >14/week or >4/occasion (men).
- Hazardous drinkers not in withdrawal: brief intervention, oral thiamine while drinking continues, GP follow-up, addiction liaison if available — not necessarily STT detox.
Note Template
Ready-to-use clinical note structure
🕒 08 / 10 / 2026 — 16:06 ATRP re: alcohol withdrawal / CIWA-Ar Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [alcohol dependence, previous DTs/seizures, liver disease] 🧾 Hx: • Last drink: [time / date] • Typical daily intake: [units] • Previous withdrawal / DTs / seizures: [yes/no] • Other substances: [benzodiazepines / opioids / other] 🩺 Exam: • Vitals: HR __ BP __ RR __ Temp __ SpO₂ __ (recorded separately) • CIWA-Ar: __ / 67 — band: [≤9 minimal / 10–19 mild–moderate / ≥20 severe] • Orientation, tremor, sweats, agitation, hallucinations: [note] 📋 Impression: Alcohol withdrawal syndrome — [minimal / mild–moderate / severe] 📌 Plan: • Symptom-triggered benzo per local protocol if threshold met (e.g. diazepam 20 mg PO if CIWA-Ar >10) • Rescore CIWA-Ar in [90 min / 30–60 min if severe] • Pabrinex / thiamine per local Wernicke prophylaxis guideline • Correct glucose / electrolytes; IV fluids as needed • Escalate if seizures, DTs, or refractory agitation • Escalated to Reg: [yes/no] 👤 [Your Name], [Role] IMC: _______
Educational reference only. Medical disclaimer