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Category Medicine & Tests

Patient ID / Name (optional)

Assessment Date & Time

1. Nausea / Vomiting 0

Observe and ask: "Do you feel sick to your stomach? Have you vomited?"

0 = None4 = Intermittent nausea7 = Constant nausea, vomiting

2. Tremor 0

Arms extended, fingers spread apart. Observe tremor.

0 = No tremor4 = Moderate (arms extended)7 = Severe (arms not extended)

3. Paroxysmal Sweats 0

Observe for visible sweating.

0 = No sweat4 = Beads on forehead7 = Drenching sweats

4. Anxiety 0

Ask: "Do you feel nervous?" Observe behavior.

0 = No anxiety4 = Moderately anxious7 = Acute panic

5. Agitation 0

Observe motor activity and restlessness.

0 = Normal activity4 = Moderately restless7 = Pacing/thrashing

6. Tactile Disturbances 0

Ask: "Do you have any itching, pins & needles, burning, or numbness? Do you feel bugs crawling on or under your skin?"

0 = None2 = Mild sensations5 = Hallucinations7 = Continuous

7. Auditory Disturbances 0

Ask: "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that disturbs you? Are you hearing things you know are not there?"

0 = Not present2 = Mild harshness5 = Hallucinations7 = Continuous

8. Visual Disturbances 0

Ask: "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that disturbs you? Are you seeing things you know are not there?"

0 = Not present2 = Mild sensitivity5 = Hallucinations7 = Continuous

9. Headache / Fullness in Head 0

Ask: "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness.

0 = Not present4 = Moderately severe7 = Extremely severe

10. Orientation / Clouding of Sensorium 0

Ask: "What day is this? Where are you? Who am I?"

0 = Oriented × 32 = Date uncertain >2 days4 = Disoriented to person

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About

The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar), quantifies the severity of alcohol withdrawal syndrome across 10 clinical domains. Each domain receives an ordinal score from 0 to 7, yielding a maximum possible score of 67. Misclassification of withdrawal severity carries direct patient risk: undertreated severe withdrawal progresses to delirium tremens with a mortality rate of 5 - 15%, while overtreating mild withdrawal exposes patients to unnecessary benzodiazepine sedation and respiratory depression. The instrument was validated by Sullivan et al. (1989) and remains the standard bedside tool in emergency departments, ICUs, and detoxification units worldwide.

This calculator implements the full 10-item CIWA-Ar protocol. Scores < 10 generally indicate minimal withdrawal not requiring pharmacotherapy. Scores ≥ 20 signal moderate-to-severe withdrawal warranting aggressive benzodiazepine dosing per institutional protocol. Note: the CIWA-Ar assumes the patient can communicate and participate in the assessment. It is unreliable in intubated, obtunded, or non-cooperative patients. Serial assessments every 1 - 2 hours are standard practice until scores stabilize below 10 for 24 hours.

Formulas

The CIWA-Ar total score is the arithmetic sum of all 10 assessed domains:

S = 10∑i=1 x_i

Where S = total CIWA-Ar score, x_i = score for domain i. Nine domains use a scale of 0 - 7 and one domain (orientation/clouding of sensorium) uses 0 - 4, giving a theoretical maximum of 67.

Severity classification follows threshold logic:

{

Minimal if S ≤ 9Mild if 10 ≤ S ≤ 15Moderate if 16 ≤ S ≤ 20Moderate-Severe if 21 ≤ S ≤ 25Severe if S ≥ 26

Where each threshold corresponds to escalating pharmacological intervention protocols per institutional guidelines.

Reference Data

Score Range	Severity	Clinical Implication	Typical Intervention	Reassessment Interval
0 - 9	Absent / Minimal	No significant withdrawal	Supportive care, thiamine, hydration	Every 4 - 8 hr
10 - 15	Mild	Early withdrawal symptoms	Consider symptom-triggered benzodiazepine	Every 2 - 4 hr
16 - 20	Moderate	Progressing withdrawal	Benzodiazepine dosing per protocol	Every 1 - 2 hr
21 - 25	Moderate-Severe	High risk for complications	Aggressive benzodiazepine, ICU consideration	Every 1 hr
26 - 67	Severe	Impending delirium tremens risk	ICU admission, IV benzodiazepines, continuous monitoring	Continuous / q 30 min
Individual Domain Scoring Reference
Nausea/Vomiting	0 - 7	0 = none; 4 = intermittent nausea; 7 = constant nausea, dry heaves, vomiting	Observe, ask patient
Tremor	0 - 7	0 = none; 4 = moderate with arms extended; 7 = severe even without extension	Arms extended, fingers spread
Paroxysmal Sweats	0 - 7	0 = none; 4 = beads of sweat on forehead; 7 = drenching sweats	Observe
Anxiety	0 - 7	0 = none; 4 = moderately anxious; 7 = panic states	Ask and observe
Agitation	0 - 7	0 = normal; 4 = moderately restless; 7 = paces or thrashes	Observe
Tactile Disturbances	0 - 7	0 = none; 2 = mild itching/burning; 5 = hallucinations; 7 = continuous hallucinations	Ask patient
Auditory Disturbances	0 - 7	0 = none; 2 = mildly harsh; 5 = hallucinations; 7 = continuous hallucinations	Ask patient
Visual Disturbances	0 - 7	0 = none; 2 = mild sensitivity; 5 = hallucinations; 7 = continuous hallucinations	Ask patient
Headache	0 - 7	0 = none; 4 = moderately severe; 7 = extremely severe	Ask: "does your head feel different?"
Orientation/Clouding	0 - 4	0 = oriented × 3; 2 = uncertain about date; 4 = disoriented to person	Ask date, place, person

Frequently Asked Questions

The orientation domain assesses three discrete cognitive anchors: person, place, and date. Sullivan et al. determined that finer granularity beyond 4 points did not improve discriminative validity for this particular domain. The remaining 9 domains capture symptom intensity on a broader continuum where a 0-7 scale provides meaningful clinical differentiation. The maximum possible CIWA-Ar score is therefore 63 (9 × 7) + 4 = 67, not 70.

For scores ≥ 20, reassess every 1 hour until stabilization. For scores 10-19, every 2-4 hours is standard. Below 10, every 4-8 hours is sufficient. Most protocols require scores below 10 for at least 24 consecutive hours before discontinuing scheduled assessments. Symptom-triggered protocols (dosing benzodiazepines only when CIWA-Ar ≥ 10) reduce total benzodiazepine dose and treatment duration compared to fixed-schedule dosing.

No. The CIWA-Ar was validated exclusively for alcohol withdrawal. Benzodiazepine withdrawal uses the CIWA-B scale. Opioid withdrawal uses the Clinical Opiate Withdrawal Scale (COWS). Using CIWA-Ar for non-alcohol withdrawal produces unreliable scores because the symptom profiles differ substantially - opioid withdrawal features rhinorrhea, piloerection, and GI cramping which CIWA-Ar does not measure.

Scores ≥ 5 on any perceptual disturbance domain indicate frank hallucinations and strongly predict progression to delirium tremens. These three domains carry disproportionate clinical weight relative to their numeric contribution to the total score. A patient scoring only 18 total but with a 6 in visual disturbances is clinically more concerning than a patient scoring 18 from diffuse mild symptoms. Clinicians should flag individual high-scoring perceptual domains regardless of the total.

Not linearly. Seizures can occur even at moderate CIWA-Ar scores (15-20), particularly within the first 24-48 hours after last drink. The CIWA-Ar does not directly predict seizures - it quantifies current symptom burden. Patients with prior withdrawal seizures have a 3× higher recurrence risk independent of their CIWA-Ar score. History of withdrawal seizures should independently trigger prophylactic benzodiazepine therapy regardless of the current CIWA-Ar value.

Hepatic encephalopathy can independently cause disorientation, agitation, and tremor - inflating CIWA-Ar scores without actual alcohol withdrawal being the cause. In patients with known cirrhosis (Child-Pugh B or C), clinicians should correlate CIWA-Ar findings with ammonia levels and temporal relationship to last alcohol intake. Additionally, impaired hepatic metabolism prolongs benzodiazepine half-life, so dosing protocols should prefer lorazepam or oxazepam (glucuronidated, not oxidized) in these patients.