CIWA-Ar for Alcohol Withdrawal Clinical Calculator and Pathways

Nausea/Vomiting

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

No Nausea and No Vomiting

0

Mild Nausea and No Vomiting

+1

(More Severe Symptoms)

+2

(More Severe Symptoms)

+3

Intermittent Nausea with Dry Heaves

+4

(More Severe Symptoms)

+5

(More Severe Symptoms)

+6

Constant Nausea, Frequenty Dry Heaves and Vomiting

+7

Tremor

Arms extended and fingers spread apart.

No Tremor

0

Not Visible, but can be felt fingertip to fingertip

+1

(More Severe Symptoms)

+2

(More Severe Symptoms)

+3

Moderate, with Patient's Arms Extendeds

+4

(More Severe Symptoms)

+5

(More Severe Symptoms)

+6

Severe, even with arms not extended

+7

Paroxysmal Sweats No Sweat Visible

0

Barely perceptible sweating, palms moist

+1

(More Severe Symptoms)

+2

(More Severe Symptoms)

+3

Beads of sweat obvious on forehead

+4

(More Severe Symptoms)

+5

(More Severe Symptoms)

+6

Drenching Sweats

+7

Anxiety

Ask, 'Do you feel nervous?'

No anxiety, at ease

0

Mildly anxious

+1

(More Severe Symptoms)

+2

(More Severe Symptoms)

+3

Moderately anxious, or guarded, so anxiety is inferred

+4

(More Severe Symptoms)

+5

(More Severe Symptoms)

+6

Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

+7

Agitation Normal Activity

0

Somewhat more activity than normal activty

+1

(More Severe Symptoms)

+2

(More Severe Symptoms)

+3

Moderately fidgety and restless

+4

(More Severe Symptoms)

+5

(More Severe Symptoms)

+6

Paces back and forth during most of the interview, or constantly thrashes about

+7

Tactile Disturbances

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

None

0

Very mild itching, pin and needles, burning, or numbness

+1

Mild itching, pin and needles, burning, or numbness

+2

Moderate itching, pin and needles, burning, or numbness

+3

Moderately severe hallucinations

+4

Severe hallucinations

+5

Extremely severe hallucinations

+6

Continous hallucinations

+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? Are you hearing things you know are not there?'

Not Present

0

Very mild harshness or ability or frighten

+1

Mild harshness or ability or frighten

+2

Moderate harshness or ability or frighten

+3

Moderately severe hallucinations

+4

Severe hallucinations

+5

Extremely severe hallucinations

+6

Continous hallucinations

+7

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? Are you seeing things you know are not there?'

Not Present

0

Very mild sensitivity

+1

Mild sensitivity

+2

Moderate sensitivity

+3

Moderately severe hallucinations

+4

Severe hallucinations

+5

Extremely severe hallucinations

+6

Continous hallucinations

+7

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. Otherwise, rate severity.

Not Present

0

Very mild

+1

Mild

+2

Moderate

+3

Moderately severe

+4

Severe

+5

Very severe

+6

Extremely severe

+7

Orientation/Clouding of Sensorium

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

Oriented, can do serial additions

0

Can't do serial additions or is uncertain about date

+1

Disoriented for date by no more than 2 calendar days

+2

Disoriented for date by more than 2 calendar days

+3

Disoriented to place or person

+4

CIWA-Ar for Alcohol Withdrawal

Interpretation