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CIWA-Ar

Alcohol

Clinical Institute Withdrawal Assessment for Alcohol, Revised

#Alcohol#Withdrawal#Clinical

Overview

The CIWA-Ar is the most widely used scale for the assessment and management of alcohol withdrawal.

Scoring & Interpretation Reference

0 - 9 Very Mild

Withdrawal symptoms are very mild. Supportive care may be sufficient.

10 - 19 Mild to Moderate

Mild to moderate withdrawal. Seek medical advice. Medication may be required to prevent complications.

20 - 67 Severe

Severe withdrawal. Seek urgent medical care immediately. High risk of complications like seizures or delirium tremens.

Scale Content & Assessment Items

Rate the patient on the following items. Sum the scores to determine the severity of withdrawal.

Nausea and Vomiting

Options: 0 - No nausea and no vomiting (0) · 1 - Mild nausea with no vomiting (1) · 2 (2) · 3 (3) · 4 - Intermittent nausea with dry heaves (4) · 5 (5) · 6 (6) · 7 - Constant nausea, frequent dry heaves and vomiting (7)

Tremor

Options: 0 - No tremor (0) · 1 - Not visible, but can be felt fingertip to fingertip (1) · 2 (2) · 3 (3) · 4 - Moderate, with patient's arms extended (4) · 5 (5) · 6 (6) · 7 - Severe, even with arms not extended (7)

Paroxysmal Sweats

Options: 0 - No sweat visible (0) · 1 - Barely perceptible sweating, palms moist (1) · 2 (2) · 3 (3) · 4 - Beads of sweat obvious on forehead (4) · 5 (5) · 6 (6) · 7 - Drenching sweats (7)

Anxiety

Options: 0 - No anxiety, at ease (0) · 1 - Mildly anxious (1) · 2 (2) · 3 (3) · 4 - Moderately anxious, or guarded, so anxiety is inferred (4) · 5 (5) · 6 (6) · 7 - Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions (7)

Agitation

Options: 0 - Normal activity (0) · 1 - Somewhat more than normal activity (1) · 2 (2) · 3 (3) · 4 - Moderately fidgety and restless (4) · 5 (5) · 6 (6) · 7 - Paces back and forth during most of the interview, or constantly thrashes about (7)

Tactile Disturbances

Options: 0 - None (0) · 1 - Very mild itch, pins and needles, burning or numbness (1) · 2 - Mild itch, pins and needles, burning or numbness (2) · 3 - Moderate itch, pins and needles, burning or numbness (3) · 4 - Moderately severe hallucinations (4) · 5 - Severe hallucinations (5) · 6 - Extremely severe hallucinations (6) · 7 - Continuous hallucinations (7)

Auditory Disturbances

Options: 0 - Not present (0) · 1 - Very mild harshness or ability to frighten (1) · 2 - Mild harshness or ability to frighten (2) · 3 - Moderate harshness or ability to frighten (3) · 4 - Moderately severe hallucinations (4) · 5 - Severe hallucinations (5) · 6 - Extremely severe hallucinations (6) · 7 - Continuous hallucinations (7)

Visual Disturbances

Options: 0 - Not present (0) · 1 - Very mild sensitivity (1) · 2 - Mild sensitivity (2) · 3 - Moderate sensitivity (3) · 4 - Moderately severe hallucinations (4) · 5 - Severe hallucinations (5) · 6 - Extremely severe hallucinations (6) · 7 - Continuous hallucinations (7)

Headache, Fullness in Head

Options: 0 - Not present (0) · 1 - Very mild (1) · 2 - Mild (2) · 3 - Moderate (3) · 4 - Moderately severe (4) · 5 - Severe (5) · 6 - Very severe (6) · 7 - Extremely severe (7)

Orientation and Clouding of Sensorium

Options: 0 - Oriented and can do serial additions (0) · 1 - Cannot do serial additions or is uncertain about date (1) · 2 - Disoriented for date by no more than 2 calendar days (2) · 3 - Disoriented for date by more than 2 calendar days (3) · 4 - Disoriented for place and/or person (4)

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