Please use I.D.
label or block print
[ ] HOSPITAL GROUP SURNAME UMRN
ALCOHOL WITHDRAWAL GIVEN NAMES DOB GENDER
CHART (CIWA-Ar) FOR
Insert HSP barcode here
ALCOHOL ONLY ADDRESS POSTCODE
WARD:
TELEPHONE
CONSULTANT:
Mandatory Checklist: Alcohol Withdrawal Seizure History (consider regular benzodiazepine*): Yes No
Date/Time Last Alcohol Consumed: ______________ Co-existing illness (reduce dose*):
Hepatic impairment or contraindication for diazepam (consider lorazepam*)
Regular thiamine prescribed* Serum magnesium checked +/- replaced
Clinical Institute Withdrawal Assessment for - Alcohol reviewed (CIWA-Ar)
Date
Time
Nausea and Vomiting (0-7)
Tremor (0-7)
Paroxysmal Sweats (0-7)
Anxiety (0-7)
Agitation (0-7)
DO NOT WRITE IN MARGIN
Tactile Disturbances (0-7)
Auditory Disturbances (0-7)
Visual Disturbances (0-7)
(CIWA-Ar)
Headache (0-7)
Orientation (0-4)
TOTAL SCORE: (max 67)
ORAL BENZODIAZEPINE IN USE DIAZEPAM LORAZEPAM
MR ### ALCOHOL WITHDRAWAL CHART
Oral Dose given (mg)
Nurse Initials
Daily Medical Review (signed)
Referral to Alcohol and Drug
Service Referred by: To: Date:
Oral Dosing Guide (reduce dose for age and/or comorbidities*)
THIS IS NOT A PRESCRIPTION - REFER TO THE WA HOSPITAL MEDICATION CHART
Oral Dose
Symptoms CIWA-Ar Score CIWA-Ar Frequency
Diazepam Lorazepam
Mild 0-8 NIL NIL Record CIWA-Ar score and repeat in FOUR hours
Moderate 9-14 5 – 15 mg 1 – 3 mg Record CIWA-Ar score and repeat in TWO hours
Record CIWA-Ar and repeat in ONE hour.
Severe 15 or more 20 mg 4 mg
If no reduction in score discuss with Medical Officer
Usual maximum per 24 hours 100 mg 20 mg Seek medical review if maximum dose reached
• Physiological observations must be recorded on the Adult Observation and Response Chart at each assessment
• Clinical features of alcohol withdrawal may overlap with signs of other illnesses. Consider other medical and
psychiatric conditions when assessing patients. Policies guiding activation of medical emergency teams for the
deteriorating patient still apply.
• This chart MUST be reviewed and signed daily by treating medical team
• Medications MUST be prescribed on the WA Hospital Medication Chart
• This Chart is ceased when at least 48 hours have elapsed since alcohol cessation AND the total score is 8 or less on
FOUR CONSECUTIVE occasions
Alcohol Withdrawal Chart (CIWA-Ar) v1.1
ALCOHOL WITHDRAWAL CHART (CIWA-Ar)
NAUSEA AND VOMITING – Ask “Do you feel sick to your TACTILE DISTURBANCES – ask “Have you any itching, pins and
stomach? Have you vomited?” Observation. needles sensations, any burning, any numbness, or do you feel bugs
crawling on or under your skin?” Observation.
0 no nausea and no vomiting 0 none
1 mild nausea with no vomiting 1 very mild itching, pins and needles, burning or numbness
2 2 mild itching, pins and needles, burning or numbness
3 3 moderate itching, pins and needles, burning or numbness
4 intermittent nausea with dry heaves 4 moderately severe hallucinations
5 5 severe hallucinations
6 6 extremely severe hallucinations
7 constant nausea, frequent dry heaves and vomiting 7 continuous hallucinations
TREMOR – Arms extended and fingers spread apart. AUDITORY DISTURBANCES – Ask “Are you more aware of sounds
Observation. around you? Are they harsh? Do they frighten you? Are you hearing
anything that is disturbing to you? Are you hearing things that you
0 no tremor know are not there?” Observation.
1 not visible, but can be felt fingertip to fingertip
2 0 not present
3 1 very mild harshness or ability to frighten
4 moderate, with patient’s arms extended 2 mild harshness or ability to frighten
5 3 moderate harshness or ability to frighten
6 4 moderately severe hallucinations
7 severe, even with arms not extended 5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations
PAROXYSMAL SWEATS – Observation. VISUAL DISTURBANCES – Ask “Does the light appear to be too
bright? Is its colour different? Does it hurt your eyes? Are you seeing
0 no sweat visible anything that is disturbing to you? Are you seeing things you know are
1 barely perceptible sweating, palms moist not there? Observation.
2
3 0 not present
4 beads of sweat obvious on forehead 1 very mild sensitivity
5 2 mild sensitivity
DO NOT WRITE IN MARGIN
6 3 moderate sensitivity
7 drenching sweats 4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations
ANXIETY – Ask “Do you feel nervous?” Observation. HEADACHE, FULLNESS IN HEAD – Ask “Does your head feel
different? Does it feel like there is a band around your head?” Do not
0 no anxiety, at ease rate for dizziness or light headedness. Otherwise, rate severity.
1 mildly anxious
2 0 not present
3 1 very mild
4 moderately anxious, or guarded, so anxiety is inferred 2 mild
5 3 moderate
6 4 moderately severe
7 equivalent to acute panic states as seen in severe 5 severe
delirium or acute schizophrenic reactions 6 very severe
7 extremely severe
AGITATION – Observation. ORIENTATION AND CLOUDING OF SENSORIUM
– Ask “What day is this? Where are you? Who am I?”
0 normal activity
1 somewhat more than normal activity 0 orientated and can perform serial additions
2 1 cannot do serial additions or is uncertain about date
3 2 disorientated for date by no more than 2 calendar days
4 moderately fidgety and restless 3 disorientated for date by more than 2 calendar days
5 4 disorientated for place / or person
6
7 paces back and forth during most of the interview, or
constantly thrashes about
THIAMINE*: patients with alcohol withdrawal and clear mental state should receive thiamine IV 300 mg daily for 3 days, then
PO 100 mg TDS. Consider IV 500mg TDS for patients with features of Wernicke’s encephalopathy. IM thiamine is a suitable
alternative for patients without IV access.
*Chart to be used in association with WA Health AOD Withdrawal Management Practice and Pathways and/or site-specific
Alcohol and other Drug management guidelines.
Treatment recommendations do not cover all clinical scenarios and do not replace the need for clinical judgement.
References:
Sullivan et al (1989) The revised Clinical Institute Withdrawal for Alcohol scale- revised (CIWA-Ar) British Journal of Addiction. 84: 1353-1357 Haber P, Lintzeris N, Proude E, Lopatko O.
Guidelines for the treatment of Alcohol Problems. (2009). Australian Government. Department of Health and Aging.
Western Australian Drug and Alcohol Authority, (2015), A Brief Guide to the Assessment and Treatment of Alcohol Dependence; 17-18.
Alcohol Withdrawal Chart (CIWA-Ar) V1.1 Endorsed by WATAG July 2021
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