CIWA Alcohol Withdrawal Scale: Understanding CIWA Scores

Question: “Do you feel sick to your stomach? Have you vomited?”

0 No nausea and no vomiting

1 Mild nausea with no vomiting

2

3

4 Intermittent nausea with dry heaves

5

6

7 Constant nausea, frequent dry heaves and vomiting

Observe by letting patients extend their arms and spread their fingers apart

0 No tremor

1 Not visible, but can be felt fingertip to fingertip

2

3

4 Moderate, with patient’s arms extended

5

6

7 Severe, even with arms not extended

Doctors will note the presence of sweat on patients.

0 No visible sweat

1 Barely perceptible sweating, palms moist

2

3

4 Beads of sweat obvious on forehead

5

6

7 Drenching sweats

Question: “Do you feel nervous?

0 No anxiety, at ease

1 Mild anxious

2

3

4 Moderately anxious, or guarded, so anxiety is inferred

5

6

7 Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

Doctors will observe patients for any signs.

0 Normal activity

1 Somewhat more than normal activity

2

3

4 Moderately fidgety and restless

5

6

7 Paces back and forth during most of the interview or constantly thrashes about

Question: “Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling or under your skin?”

0 None

1 Very mild itching, pins and needles, burning or numbness

2 Mild itching, pins and needles, burning or numbness

3 Moderate itching, pins and needles, burning or numbness

4 Moderately severe hallucinations

5 Severe hallucinations

6 Extremely severe hallucinations

7 Continuous hallucinations

Question: “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?”

0 Not present

1 Very mild harshness or ability to frighten

2 Mild harshness or ability to frighten

3 Moderate harshness or ability to frighten

4 Moderately severe hallucinations

5 Severe hallucinations

6 Extremely severe hallucinations

7 Continuous hallucinations

Question: “Does the light appear to be 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?”

0 Not present

1 Very mild sensitivity

2 Mild sensitivity

3 Moderate sensitivity

4 Moderately severe hallucinations

5 Severe hallucinations

6 Extremely severe hallucinations

7 Continuous hallucinations

Question: “Does your head feel different? Does it feel like there is a band around your head?”

0 No present

1 Very mild

2 Mild

3 Moderate

4 Moderately severe

5 Severe

6 Very severe

7 Extremely severe

Question: “What day is this? Where are you? Who am I?”

0 Oriented and can do serial additions

1 Cannot do serial additions or is uncertain about date

2 Disoriented for date by no more than 2 calendar days

3 Disoriented for date by more than 2 calendar days

4 Disoriented for place/or person