Clinical Institute Withdrawal Assessment (CIWA) in the ED

  • Alcohol is responsible for 40% of drug-related emergency department (ED) visits and over 140,000 deaths annually in the United States. 
  • ED visits involving acute alcohol consumption are more complex and can result in higher inpatient hospitalization and ICU admissions, increasing the use of critical care resources. 
  • To treat alcohol withdrawal syndrome in the ED, healthcare professionals can use the CIWA-AR scale, which helps assess and manage withdrawal symptoms and optimize patient safety.

R.E. Hengsterman


April 26, 2023
Simmons University

Alcohol Overdose and CIWA

Alcohol related admissions to the emergency department before the pandemic neared a million visits. In fact, alcohol accounts for 40% of drug-related ED visits, followed by opioids, methamphetamines, marijuana and cocaine.  

Alcohol use disorder (AUD) and excessive drinking accounts for over 140,000 deaths each year in the United States. The pandemic, coupled with mounting economic hardships, has increased alcohol consumption, and may hint at the effects of post pandemic and economic-related stress.  


CIWA in the ED

The Role of Emergency Departments (EDs) in Treating Alcohol Overdose

Emergency department (ED) visits involving acute alcohol consumption offer an added layer of complexity and acuity to the ED population with higher inpatient hospitalization, higher ICU admissions and increased use of critical care resources.

Because of staffing and capacity issues in most healthcare settings, many individuals with alcohol related admissions end up waiting in EDs for extended lengths of time. This “boarding” crisis can be detrimental to patients and staff and increases patients’ risk of withdrawal related complications.

Knowledgeable emergency room and frontline staff can recognize alcohol withdrawal syndrome (AWS) and the potential for life-threatening outcomes. 

Utilizing CIWA to Treat AWS

There are tools and protocols that exist in most EDs designed to increase patient safety and prevent harmful outcomes. The (CIWA-AR) scale is a revised tool to decrease the risk of complications, assess, and manage alcohol withdrawal and optimize patient safety.  

The 10-item scale that quantifies the severity of the alcohol withdrawal syndrome offers usefulness, validity, and reliability in measuring a patients symptomology including auditory, visual, and tactile disturbances. As with any tool, limitations of CIWA-AR exist.

In a demanding emergency department, administering the tool hourly can be cumbersome. The tool requires the patient to have the capabilities to answer the questions. Confounding psychiatric conditions and comorbidities may alter the tools validity.  

Emergency room staff can incorporate CIWA-AR into their clinical care. Nurses and healthcare professionals can complete the assessment in less than 2 minutes. The cumulative score of the ten symptoms determines a severity range for a patient’s withdrawal syndrome, with each category scored with a max of seven points.

A total score between 8-10 indicates mild withdrawal. A score between 8-15 shows moderate withdrawal. Scores of fifteen or more indicates severe withdrawal and an increased risk for delirium tremens (DTs). The ten alcohol withdrawal symptoms measured include: 

  1. Agitation (0-7) 
  2. Anxiety (0-7) 
  3. Auditory disturbances (0-7) 
  4. Clouding of sensorium (0-7) 
  5. Headache (0-7) 
  6. Nausea/vomiting (0-7) 
  7. Paroxysmal sweats (0-7) 
  8. Tactile disturbances (0-7) 
  9. Tremor (0-7) 
  10. Visual disturbances (0-7) 

CIWA in the ER

Symptoms of AWS

Early withdrawal symptoms arise from central nervous system hyperactivity manifesting as tachycardia, tachypnea, hypertension, diaphoresis, and hyperthermia which can present within six hours of the patient’s last drink.

Additional symptoms include nausea, GI distress, headache, anxiety, and tremors with patients still having a significant blood alcohol concentration while they wait in the emergency department. At the eight-to-twelve-hour mark, patients can experience auditory, visual, and tactile hallucinations, paranoia, and delusions. Generalized tonic-clonic seizures can occur within 12-24 hours after the patient’s last drink.

Within 24-72 hours of the patients last alcohol consumption, confusion can progress to altered levels of consciousness, severe autonomic dysfunction, and persistent hallucinations. The progression of symptoms and time of onset can vary between patients.  

A Case Study Using CIWA

A 53-year-old man arrives at the emergency department after being involved in a low-speed ATV accident while intoxicated. His Glasgow Coma Scale (GCS) score was thirteen and his serum ethanol level less than 100 mmol/L. The patient’s past medical history included depression and alcohol abuse, consuming at least seven drinks daily. After suturing a minor facial laceration and getting a computed tomography scan of his head, the radiologist reported a trace subarachnoid hemorrhage. After consultation, neurosurgery admitted the patient for observation. While awaiting an inpatient bed, the nurse ED observed the patient experience diaphoresis, nausea, and tachycardia (149 beats/min). Suspecting the potential of alcohol withdrawal syndrome, the nurse implemented the (CIWA-AR) tool. The patient had an initial score of 16. Providers placed the patient on benzodiazepine taper, with diazepam 5 mg IV every 20 minutes to achieve symptom control, and then diazepam 5 mg IV every 4 hours for maintenance.  

The goals of initial treatment with benzodiazepines are to control the alcohol withdrawal symptoms and improve autonomic hyperactivity (temperature, heart rate, and blood pressure) along with seizure prevention. For patients, alcohol related emergency department visits can be a life-saving encounter if clinicians recognize their role in treating the potential life-threatening effects of alcohol withdrawal. 

CIWA assessment

The Bottom Line on CIWA

In conclusion, alcohol-related admissions to the emergency department have been on the rise, and this trend has been exacerbated by the pandemic and economic hardships. As a result, healthcare professionals need to be well-equipped to recognize and treat alcohol withdrawal syndrome (AWS) to prevent harmful outcomes. The use of tools like the CIWA-AR scale can help clinicians assess and manage AWS, ultimately improving patient outcomes and preventing life-threatening complications. 

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