CIWA Calculator (CIWA-Ar Scale)

Assess the severity of alcohol withdrawal using the revised Clinical Institute Withdrawal Assessment (CIWA-Ar) scale. Score all 10 items below to determine the need for pharmacological treatment.

1 Nausea and Vomiting

Ask "Do you feel sick to your stomach? Have you vomited?"

2 Tremor

Arms extended and fingers spread apart.

3 Paroxysmal Sweats

Observation of sweating.

4 Anxiety

Ask "Do you feel nervous?" Observation.

5 Agitation

Observation of patient's behavior.

6 Tactile Disturbances

Ask "Have you any itching, pins and needles sensations, burning, numbness, or do you feel bugs crawling on or under your skin?"

7 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?"

8 Visual Disturbances

Ask "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?"

9 Headache, Fullness in Head

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

10 Orientation and Clouding of Sensorium

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

Score Breakdown

Category Score
Total

What is the CIWA Scale?

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a standardized clinical tool used to assess the severity of alcohol withdrawal syndrome. Originally developed in 1981, the scale provides clinicians with a structured, quantitative method to evaluate and monitor patients experiencing alcohol withdrawal.

The tool helps healthcare providers determine whether a patient requires pharmacological treatment (such as benzodiazepines) and guides the dosing of such medications. It is one of the most widely used instruments in emergency departments, detoxification centers, and inpatient settings worldwide.

CIWA-Ar: The Revised Version

Sullivan et al. revised the CIWA protocol in 1989, shortening the number of items from 15 to 10. This revised version, known as CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, Revised), is the version most commonly used in clinical practice today. The 10 assessment items are:

  1. Nausea and Vomiting (0-7)
  2. Tremor (0-7)
  3. Paroxysmal Sweats (0-7)
  4. Anxiety (0-7)
  5. Agitation (0-7)
  6. Tactile Disturbances (0-7)
  7. Auditory Disturbances (0-7)
  8. Visual Disturbances (0-7)
  9. Headache, Fullness in Head (0-7)
  10. Orientation and Clouding of Sensorium (0-4)

CIWA Score Ranges and Interpretation

Each of the 10 items in CIWA-Ar scores from 0 to 7 points, except the "Orientation" category, which can score from 0 to 4 points. Therefore, the maximal alcohol withdrawal score is 67.

Score Range Severity Clinical Action
< 10 Mild withdrawal Pharmacological treatment is generally not indicated
10 – 20 Moderate withdrawal Clinical judgment needed to determine if pharmacological treatment is required
> 20 Severe withdrawal Indicative of severe withdrawal; pharmacological treatment is strongly recommended

How to Use the CIWA Calculator

To properly assess a patient using the CIWA-Ar scale, follow these steps:

  1. Observe the patient carefully and note any visible signs of withdrawal (tremor, sweating, agitation).
  2. Ask the patient the specific questions listed for each category (nausea, anxiety, headache, etc.).
  3. Rate each of the 10 items on the provided scale.
  4. Sum the scores to obtain the total CIWA-Ar score.
  5. Interpret the total score using the ranges above to guide clinical decision-making.

The assessment should be performed every 1-2 hours initially, with frequency adjusted based on the patient's condition. Ideally, the score should be reassessed after any medication administration.

Alcohol Withdrawal Syndrome

Alcohol withdrawal syndrome (AWS) occurs when a person who has been drinking heavily for an extended period suddenly stops or significantly reduces their alcohol consumption. The severity of withdrawal depends on multiple factors including:

Symptoms of alcohol withdrawal typically appear within 6-24 hours after the last drink and can range from mild anxiety and tremors to life-threatening seizures and delirium tremens (DTs). The most dangerous period is usually between 48 and 72 hours after cessation.

Frequently Asked Questions

What is the maximum CIWA score?

The maximum possible CIWA-Ar score is 67. This is calculated from 9 items scoring 0-7 (maximum 63) plus the orientation item scoring 0-4.

How often should CIWA scoring be performed?

Initially, CIWA scoring should be done every 1-2 hours. If scores remain below 10 for 24 hours, the frequency can be reduced. After medication administration, reassessment should occur within 1 hour.

Can CIWA be used for benzodiazepine withdrawal?

No. The CIWA-Ar scale is specifically designed for alcohol withdrawal. For benzodiazepine withdrawal, other validated tools should be used, such as the Benzodiazepine Withdrawal Symptom Questionnaire (BWSQ).

What medications are typically used for alcohol withdrawal?

Benzodiazepines (such as chlordiazepoxide, diazepam, or lorazepam) are the first-line treatment for alcohol withdrawal. The choice and dose depend on the CIWA score, the patient's liver function, and other clinical factors.

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