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| {{SI}}
| | #redirect[[Alcohol withdrawal#Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar)]] |
| {{EH}}
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| ===Scoring===
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| '''Total score is a simple sum of each score item (maximum is 67)'''
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| <br>
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| <10: ''Very mild withdrawal''<br>
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| 10-15: ''Mild withdrawal'' <br>
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| 16-20: ''Modest withdrawal'' <br>
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| >20: ''Severe withdrawal'' <br>
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| ===Nausea and vomiting===
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| 0 No nausea and vomiting <br>
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| 1 <br>
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| 2 <br>
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| 3 <br>
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| 4 Intermittent nausea with dry heaves <br>
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| 5 <br>
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| 6 <br>
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| 7 Constant nausea, frequent dry heaves and vomiting <br>
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| ===Paroxysmal sweats===
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| 0 No sweats visible <br>
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| 1 Barely visible sweating, palms moist <br>
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| 2 <br>
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| 3 <br>
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| 4 Beads of sweat obvious on forehead <br>
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| 5 <br>
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| 6 <br>
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| 7 Drenching sweats <br>
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| ===Anxiety===
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| 0 No anxiety <br>
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| 1 <br>
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| 2 <br>
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| 3 <br>
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| 4 Moderately anxious, guarded <br>
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| 5 <br>
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| 6 <br>
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| 7 Acute panic state, consistent with severe delirium or acute schizophrenia <br>
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| ===Agitation===
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| 0 Normal activity <br>
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| 1 Somewhat more than normal activity <br>
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| 2 <br>
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| 3 <br>
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| 4 Moderately fidgety and restless <br>
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| 5 <br>
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| 6 <br>
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| 7 Paces back and forth during most of the interview or constantly thrashes about <br>
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| ===Tremor===
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| 0 No tremor <br>
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| 1 Not visible, but can be felt at fingertips <br>
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| 2 <br>
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| 3 <br>
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| 4 Moderate when patient's hands extended <br>
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| 5 <br>
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| 6 <br>
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| 7 Severe, even with arms not extended <br>
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| ===Headache===
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| 0 Not present <br>
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| 1 Very mild <br>
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| 2 Mild <br>
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| 3 Moderate <br>
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| 4 Moderately severe <br>
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| 5 Severe <br>
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| 6 Very severe <br>
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| 7 Extremely severe <br>
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| ===Auditory disturbances===
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| 0 Not present <br>
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| 1 Very mild harshness or ability to frighten <br>
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| 2 Mild harshness or ability to frighten <br>
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| 3 Moderate harshness or ability to frighten <br>
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| 4 Moderately severe hallucinations <br>
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| 5 Severe hallucinations <br>
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| 6 Extremely severe hallucinations <br>
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| 7 Continuous hallucinations <br>
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| ===Visual disturbances===
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| 0 Not present <br>
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| 1 Very mild photosensitivity <br>
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| 2 Mild photosensitivity <br>
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| 3 Moderate photosensitivity <br>
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| 4 Moderately severe visual hallucinations <br>
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| 5 Severe visual hallucinations <br>
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| 6 Extremely severe visual hallucinations <br>
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| 7 Continuous visual hallucinations <br>
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| ===Tactile disturbances===
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| 0 None <br>
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| 1 Very mild paresthesias <br>
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| 2 Mild paresthesias <br>
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| 3 Moderate paresthesias <br>
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| 4 Moderately severe hallucinations <br>
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| 5 Severe hallucinations <br>
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| 6 Extremely severe hallucinations <br>
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| 7 Continuous hallucinations <br>
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| ===Orientation and clouding of sensorium===
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| 0 Orientated and can do serial additions <br>
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| 1 Cannot do serial additions <br>
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| 2 Disoriented for date by no more than 2 calendar days <br>
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| 3 Disoriented for date by more than 2 calendar days <br>
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| 4 Disoriented for place and/or patient <br>
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| ==Acknowledgements==
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| Content on this page came in part from UpToDate
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| {{SIB}}
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| [[Category:Critical pathways]]
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| {{WH}}
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| {{WS}}
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