TOX CARDS: CIWA-AR

Author: Brian P. Murray, DO (@bpatmurray Senior EM Resident Physician, Resident Brooke Army Medical Center) // Edited by: Cynthia Santos, MD (Senior Medical Toxicology Fellow, Emory University School of Medicine), Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital), and Brit Long, MD (@long_brit)

Case Presentation:

A 53-year-old man presents to the Emergency Department with a history of 12 alcoholics drinks daily. His last drink was 24 hours ago, and he is feeling anxious and jittery. Vital signs: HR 90, BP 135/90, RR 18, T 98.9^oF, SpO₂ 97% room air.  

Question:

How can you determine the severity of withdrawal and the need for inpatient versus outpatient management?

Pearl:

The use of the 10 item CIWA-AR score is a rapid and effective tool that can help objectively rate the level of alcohol withdrawal. [1]

• Alcohol withdrawal syndrome is a spectrum of disorders ranging from mild symptoms to life threatening seizures and delirium tremens. [2]
• The CIWA-AR score cannot differentiate the different types of alcohol withdrawal syndromes nor between delirium tremens and medical causes of delirium. [3]
• The score ranges from 0 (no withdrawal) to 67 (severe withdrawal) and can be easily repeated for evaluation of worsening or improving withdrawal.
• The score incorporates the scores from the categories “Nausea and Vomiting” (0-7), “Tremors” (0-7), “Paroxysmal Sweats” (0-7), “Anxiety” (0-7), “Agitation” (0-7), “Tactile Disturbance” (0-7), “Auditory Disturbance” (0-7), “Visual Disturbance” (0-7), “Headache of Fullness” (0-7), and “Clouding of Sensorium” (0-4).
• A score of 0-9 is considered mild withdrawal and can be managed as an outpatient with supportive can with or without medical management, at the discretion of the physician.
• A score of 10-19 is considered moderate withdrawal and should be considered for admission for acute medical detoxification.
• A score of >20 is considered severe withdrawal and the patient should be admitted to a high acuity unit, such as an ICU, for close monitoring and medical detoxification.
• If the CIWA-AR score remains high even after adequate medical management, the patient likely has a comorbid medical delirium. [4]
• A similar 20 item CIWA-B score is also available for use with acute benzodiazepine withdrawal. [5]

Main Point:

The CIWA-AR score is an effective tool that can be employed in less than 5 minutes to objectively score the level of withdrawal. It can also be repeated to assess efficacy of treatment of progression of withdrawal. The tool can be useful in determining the ultimate disposition of the patient; whether they can be discharged to outpatient care (score 0-9), require floor admission (10-19), or ICU admission (score >20).

References:

1.      Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA‐Ar). British journal of addiction. 1989 Nov 1;84(11):1353-7.

2.      Kattimani S, Bharadwaj B. Clinical management of alcohol withdrawal: A systematic review. Industrial psychiatry journal. 2013 Jul;22(2):100.

3.      Chabria SB. Inpatient management of alcohol withdrawal: A practical approach. Signa Vitae. 2008;3:24–9.

4.      Bharadwaj B, Bernard M, Kattimani S, Rajkumar RP. Determinants of success of loading dose diazepam for alcohol withdrawal: A chart review. Journal of Pharmacology and Pharmacotherapeutics. 2012 Jul 1;3(3):270.

5.      Busto UE, Sykora K, Sellers EM. A clinical scale to assess benzodiazepine withdrawal. Journal of clinical psychopharmacology. 1989 Dec 1;9(6):412-6.