1. Utilizing the Adult Alcohol Withdrawal Syndrome Order form & CIWA-Ar tool Prepared by Buffalo General Hospital Departments of Pharmacy and Clinical Education April 2010

2. Alcohol Withdrawal Syndrome (AWS)
Definition: discontinuation or reduction of prolonged, heavy alcohol use that results in minor or major withdrawal symptoms.
Minor withdrawal symptoms include: tremor, hypertension, diaphoresis and tachycardia.
Symptoms can occur within 6-12 hours from last drink.
Serious withdrawal complications include: seizures and delirium tremens (DTs).
Symptoms can occur within hours from last drink.
Severity of symptoms is related to amount of alcohol intake and duration of patient’s recent drinking habit.

3. Clinical Institute Withdrawal Assessment for Alcohol Scale, revised (CIWA-Ar)
This assessment scale:
Objectively assesses patients for the development of acute alcohol withdrawal.
Has well-documented reliability and validity.
Is a 10-item scale that assesses the severity of withdrawal.
Serves as a basis for prescribing medication management.

4. CIWA-Ar This 10-item scale can be located in 2 places:
On the back of the order form (requires addition calculation) or
by using an online CIWA-Ar calculator that can be placed on a computer desktop.
The 10 items to be assessed are:
Nausea & vomiting Visual disturbances
Headache, fullness in head Agitation
Paroxysmal sweats Tactile disturbances
Auditory disturbances Tremor
Anxiety Orientation & clouding
of sensorium

5. On the back of the order form:

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Calculator: CIWA-Ar clinical institute withdrawal assessment for alcohol scale
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On line Calculator: CIWA-Ar Clinical Institute Withdrawal Assessment for Alcohol Scale
Disoriented for place and/or person (4 points)
  Total Criteria Point Count:  
   
Sample sections: 
NAUSEA AND VOMITING: Ask "Do you feel sick to your stomach? Have you vomited?" Observation. -No nausea and no vomiting (0 points) -Mild nausea with no vomiting (1 point) -Intermittent nausea with dry heaves (4 points) -Constant nausea, frequent dry heaves and vomiting (7 points)
TREMOR: Arms extended and fingers spread apart. Observation -No tremor (0 points) -Not visible, but can be felt fingertip to fingertip (1 point) -Moderate, with patient's arms extended (4 points) -Severe, even with arms not extended (7 points)
PAROXYSMAL SWEATS: Observation -No sweat visible (0 points) -Barely perceptible sweating, palms moist (1 point) -Beads of sweat obvious on forehead (4 points) -Drenching sweats (7 points)
ANXIETY: Ask "Do you feel nervous?" Observation. -No anxiety, at ease (0 points) -Mildly anxious (1 point) -Moderately anxious, or guarded, so anxiety is inferred (4 points) -Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions (7 points)
AGITATION: Observation -Normal activity (0 points) -Somewhat more than normal activity (1 point) -Moderately fidgety and restless (4 points) -Paces back and forth during most of the interview, or constantly thrashes about (7 points)
Calculator: CIWA-Ar Clinical Institute Withdrawal Assessment for Alcohol Scale  
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TACTILE DISTURBANCES: Ask "Have you any itching, pins and needles sensations, burning sensations, numbness or do you feel bugs crawling on or under your skin?" Observation.
VISUAL DISTURBANCES: Ask "Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation.
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?" Observation.
HEADACHE, FULLNESS IN HEAD: Ask "Does your head feel different? Does it feel as if there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity.
Continuous hallucinations (7 points)
Extremely severe hallucinations (6 points)
Cannot do serial additions or is uncertain about date (1 point)
Oriented and can do serial additions (0 points)
Very mild sensitivity (1 point)
Not present (0 points)
Severe hallucinations (5 points)
Moderately severe hallucinations (4 points)
Very mild harshness or ability to frighten (1 point)
Disoriented for date by more than 2 calendar days (3 points)
Disoriented for date by no more than 2 calendar days (2 points)
Mild harshness or ability to frighten (2 points)
Moderate harshness or ability to frighten (3 points)
Mild sensitivity (2 points)
Moderate sensitivity (3 points)
Moderate (3 points)
Mild (2 points)
Moderately severe (4 points)
Severe (5 points)
Extremely severe (7 points)
Very severe (6 points)
Very mild (1 point)
Not present (0 points)
Severe hallucinations (5 points)
Moderately severe hallucinations (4 points)
Extremely severe hallucinations (6 points)
Continuous hallucinations (7 points)
Not present (0 points)
ORIENTATION AND CLOUDING OF SENSORIUM: Ask "What day is this? Where are you? Who am I? Count forward by 3
Extremely severe hallucinations (6 points)
PAROXYSMAL SWEATS: Observation
Severe, even with arms not extended (7 points)
Moderate, with patient's arms extended (4 points)
No sweat visible (0 points)
Barely perceptible sweating, palms moist (1 point)
Drenching sweats (7 points)
Beads of sweat obvious on forehead (4 points)
Not visible, but can be felt fingertip to fingertip (1 point)
No tremor (0 points)
No nausea and no vomiting (0 points)
NAUSEA AND VOMITING: Ask "Do you feel sick to your stomach? Have you vomited?" Observation.
Mild nausea with no vomiting (1 point)
Intermittent nausea with dry heaves (4 points)
TREMOR: Arms extended and fingers spread apart. Observation
Constant nausea, frequent dry heaves and vomiting (7 points)
Continuous hallucinations (7 points)
ANXIETY: Ask "Do you feel nervous?" Observation.
Very mild itching, pins and needles, burning or numbness (1 point)
None (0 points)
Mild itching, pins and needles, burning or numbness (2 points)
Moderate itching, pins and needles, burning or numbness (3 points)
Severe hallucinations (5 points)
Moderately severe hallucinations (4 points)
Paces back and forth during most of the interview, or constantly thrashes about (7 points)
Moderately fidgety and restless (4 points)
Moderately anxious, or guarded, so anxiety is inferred (4 points)
Mildly anxious (1 point)
Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions (7 points)
AGITATION: Observation
Somewhat more than normal activity (1 point)
Normal activity (0 points)
No anxiety, at ease (0 points)
CIWA Score Interpretation  
  References
Stuppaeck CH, Barnas C et al. Assessment of the alcohol withdrawal syndrome - validity and reliability of the translated and modified Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-A). Addiction. 1994; 89:
Sullivan JT, Sykora K et al. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addiction. 1989; 89:

7. CIWA-Ar Score Total score is a simple sum of each item score
(maximum score is 67)
less than 10 = very mild withdrawal
= mild withdrawal
= modest withdrawal
greater than 20 = severe withdrawal

8. Adult Alcohol Withdrawal Syndrome Orders A new form developed to incorporate the CIWA-Ar assessment scale as well as physician orders to manage the patient’s alcohol withdrawal safely

9. Front of form

10. CIWA-Ar Documentation
Prescriber to fill in first CIWA-Ar score in “Monitoring” section.
Prescriber will check the desired protocol in the table.

11. CIWA-Ar Calculation and Documentation
Registered Nurse must obtain all subsequent CIWA-Ar scores and document in “Alteration in Neurological Status” section of the “Adult Patient Plan of Care Record” (write in on blank line)
Frequency of patient assessment and scoring is dictated by the protocol table at bottom of the order form.
CIWA-Ar Score 3

12. CIWA-Ar Online Calculator*
*Note: check your desktop on WOWs FIRST…the CIWA- Ar calculator icon may already be there!
Available from “UpToDate” and can be placed on computer desktop by following these steps:
Go to “Kaleidascope” home page
Click on “Applications” tab
Click on “UpToDate.com” then enter “UpToDate.com” button then “Accept” button
Click on “Calculators” tab
Click on “Primary Care Calculators”
Right click on “Calculator: CIWA-Ar Clinical Institute Withdrawal Assessment for Alcohol Scale” and select “Copy Shortcut”
Go to desktop and right click in blank area and select “Paste Shortcut”

13. Frequency of Assessing CIWA-Ar Score
Frequency of score depends on current CIWA-Ar* score:
If score is 1-9: repeat score q4h while awake,
until score is less than 10 for 24 hours;
then repeat score q8h for 48 hours
If score is 10-15: repeat score q2h
If score is 16-20: repeat score q2h
If score is greater than 20: repeat score q1h or as clinically indicated along with vital signs.
* Higher Score indicates more severe symptoms, necessitating more frequent patient assessment

14. Duration of Order Set
The protocol is to be discontinued when the CIWA-Ar score has been less than 10 for 72 hours.

15. Scenario 1-Introduction
A 47 year old male is admitted with diagnosis of cellulitis.
The Adult Alcohol Withdrawal Syndrome Orders were initiated- and the Lorazepam protocol was selected based on his symptoms and history.
Patient Assessment:
is awake, alert & oriented X 3
complains of being a little nauseous but has not vomited
has a very mild headache
feels a little anxious
The patient does not have:
any visual, auditory or tactile disturbances;
paroxysmal sweats
agitation or
tremors.
The patient states he drinks approximately 2-3 beers/day.

16. Scenario 1 (continued)
Use this chart to determine his CIWA-Ar Score.

17. Scenario 1-What is his CIWA-Ar Score?
Answer=3

18. Scenario 1-continued What medication should be administered?
When should the CIWA-Ar score be repeated?

19. Scenario 1 answers What is his CIWA-Ar Score? 3
What medication should he receive?
No medication necessary
When should the CIWA-Ar Score be repeated?
Every 4 hours while awake

20. Scenario 2
8 hours later the patient is still awake, alert & oriented x 3 and has the following:
Intermittent nausea with dry heaves
Moderate headache
Sweat seen on forehead
Moderately anxious
Moderately fidgety
Severe tremors even without arms being extended
Patient does not have auditory, visual or tactile disturbances

21. Scenario 2-continued
What is the patient’s CIWA-Ar score now?

22. Scenario 2-What is his CIWA-Ar Score now?
Answer=26

23. Scenario 2-continued What medication should be administered?
When should the CIWA-Ar score be repeated?
Should any additional interventions be initiated?

24. Scenario 2 (answers) What is his CIWA-Ar Score now? 26
What medication should he receive?
Lorazepam 3mg po NOW and every 1 hour as needed
When should the CIWA-Ar Score be repeated?
Every hour along with vital signs
Should any additional interventions be initiated?
Yes, contact prescriber to evaluate; document assessment and interventions in patient’s chart

25. Conclusion The CIWA-Ar scale is a very useful tool to:
Measure severity of withdrawal symptoms
Guide medication administration based on severity of symptoms
Assure patient safety during withdrawal