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Emergency Department Alcohol Withdrawal (CIWA-Ar)

CIWA-Ar protocol for symptom-triggered benzodiazepine therapy and prevention of delirium tremens.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Acil Servis department. Book Appointment →

What is Emergency Department Alcohol Withdrawal (CIWA-Ar)?

Alcohol withdrawal is a clinical syndrome that develops 6-72 hours after the last drink in dependent individuals and ranges from minor anxiety, tremor and tachycardia to seizures (12-48 h) and delirium tremens (DT, 48-96 h) which carries a mortality of 1-5% if untreated.

The Clinical Institute Withdrawal Assessment-Alcohol revised (CIWA-Ar) is a validated 10-item scale that quantifies severity and is used to deliver symptom-triggered benzodiazepine therapy (lorazepam, diazepam, oxazepam) titrated to score with frequent reassessment.

Critical adjuncts include immediate parenteral thiamine 100-500 mg before glucose to prevent Wernicke encephalopathy, magnesium and potassium replacement, hydration, treatment of comorbid infection and gastritis, and consideration of phenobarbital or dexmedetomidine for refractory cases.

Symptoms

Tremor, anxiety and agitation
Tachycardia, hypertension and sweating
Nausea, vomiting and headache
Insomnia and nightmares
Generalised tonic-clonic seizures
Tactile, visual and auditory hallucinations
Delirium tremens with autonomic instability

Risk Factors

Chronic heavy alcohol use
Previous withdrawal seizure or DT
Daily consumption >8 standard drinks
Coexisting benzodiazepine dependence
Hepatic disease and electrolyte disturbance
Older age and infection
Polysubstance use

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Recent alcohol cessation with tremor and anxiety
  • Withdrawal seizure
  • Hallucinations or delirium
  • Severe vomiting and dehydration

Treatment Methods

01
CIWA-Ar scoring on arrival and every 1-4 h
02
Symptom-triggered lorazepam or diazepam
03
Parenteral thiamine 100-500 mg before glucose
04
Magnesium, potassium and IV fluid replacement
05
Phenobarbital or dexmedetomidine for refractory DT
06
ICU admission for severe DT and instability
07
Long-term referral for alcohol use disorder treatment

Which Department to Visit?

You can visit our Acil Servis department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.