II. Indications: Alcohol Detoxification
- Alcohol Withdrawal assessment
- Scale used to direct Benzodiazepine protocol
III. Technique
- Each criteria rated on scale of 0 to 7 (except orientation)
- Maximum score: 67
IV. Criteria
-
Nausea, Vomiting
- Score 0: None
- Score 4: Intermittent
- Score 7: Constant
- Tremor
- Paroxysmal Sweating
- Score 0: None
- Score 1: Palms moist
- Score 4: Forehead beads of sweat
- Score 7: Drenched
- Anxiety
- Score 0: None
- Score 1: Mild
- Score 4: Moderate
- Score 7: Severe Panic Attack
-
Agitation
- Score 0: None
- Score 4: Fidgets, Restless
- Score 7: Paces or thrashes
- Tactile Dysfunction
- Score 0: None
- Score 3: Paresthesias
- Score 5: Severe Tactile Hallucinations
- Score 7: Continuous Tactile Hallucinations
- Auditory Disturbances
- Score 0: None
- Score 4: Hallucinations
- Score 7: Continuous
- Visual Disturbances
- Score 0: None
- Score 2: Mild Light Sensitivity
- Score 4: Moderate Visual Hallucinations
- Score 7: Continuous Visual Hallucinations
-
Headache
- Score 0: None
- Score 3: Moderate
- Score 5: Severe
- Score 7: Extreme
- Orientation
- Score 0: Oriented and Can Perform Serial Addition
- Score 1: Cannot Perform Serial Addition, Unsure of Date
- Score 2: Disoriented Regarding Date, But Within 2 Calendar Days
- Score 3: Disoriented Regarding Date By >2 Calendar Days
- Score 4: Disoriented to Place
V. Interpretation
- Mild Alcohol Withdrawal: CIWA <8
- Moderate Alcohol Withdrawal: CIWA 8 to 15
- Severe Alcohol Withdrawal: CIWA >15
VI. Resources
- CIWA-Ar Html version