Review
Copyright ©The Author(s) 2015.
World J Gastroenterol. Jul 28, 2015; 21(28): 8516-8526
Published online Jul 28, 2015. doi: 10.3748/wjg.v21.i28.8516
Table 2 Clinical institute withdrawal assessment of alcohol scale, revised (CIWA-ar)
Clinical institute withdrawal assessment of alcohol scale, revised (CIWA-AR)
Patient:_____ Date: _____ Time: _____ (24 h clock, midnight = 00:00)
Pulse or heart rate, taken for one minute:_____ Blood pressure:_____
Nausea and vomiting -- Ask "Do you feel sick to your stomach? Have you vomited?" ObservationTactile 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?" Observation
0 no nausea and no vomiting0 none
1 mild nausea with no vomiting1 very mild itching, pins and needles, burning or numbness
22 mild itching, pins and needles, burning or numbness
33 moderate itching, pins and needles, burning or numbness
4 intermittent nausea with dry heaves4 moderately severe hallucinations
55 severe hallucinations
66 extremely severe hallucinations
7 constant nausea, frequent dry heaves and vomiting7 continuous hallucinations
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?" ObservationAuditory 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?" Observation
0 not present0 not present
1 very mild sensitivity1 very mild harshness or ability to frighten
2 mild sensitivity2 mild harshness or ability to frighten
3 moderate sensitivity3 moderate harshness or ability to frighten
4 moderately severe hallucinations4 moderately severe hallucinations
5 severe hallucinations5 severe hallucinations
6 extremely severe hallucinations7 continuous hallucinations6 extremely severe hallucinations7 continuous hallucinations
Tremor -- Arms extended and fingers spread apart. ObservationParoxysmal sweats -- Observation
0 no tremor0 no sweat visible
1 not visible, but can be felt fingertip to fingertip1 barely perceptible sweating, palms moist
22
33
4 moderate, with patient's arms extended4 beads of sweat obvious on forehead
55
66
7 severe, even with arms not extended7 drenching sweats
Anxiety -- Ask "Do you feel nervous?" ObservationHeadache, 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
0 no anxiety, at ease0 not present
1 mild anxious1 very mild
22 mild
33 moderate
4 moderately anxious, or guarded, so anxiety is inferred4 moderately severe
55 severe
66 very severe
7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions7 extremely severe
Agitation -- ObservationOrientation and clouding of sensorium -- Ask "What day is this? Where are you? Who am I?"
0 normal activity0 oriented and can do serial additions
1 somewhat more than normal activity1 cannot do serial additions or is uncertain about date
22 disoriented for date by no more than 2 calendar days
33 disoriented for date by more than 2 calendar days
4 moderately fidgety and restless4 disoriented for place/or person
5
6
7 paces back and forth during most of the interview, or constantly thrashes about
Total CIWA-Ar Score ______
Rater's Initials ______
Maximum Possible Score 67