EP 188: CIWA protocol and Management of Alcohol Withdrawal

EP 188: CIWA protocol and Management of Alcohol Withdrawal

CIWA Protocol and Management of Alcohol Withdrawal

Using CIWA protocol and management of alcohol withdrawal is essential to every alcoholic individual who wants to stay sober. Keep in mind that alcohol dependency does not happen overnight.

It takes years of alcohol consumption to be called an alcoholic.

But why do people drink? What can they gain from it? When a person decides to stay sober, they go through all kinds of changes as their body withdraws from it.

Alcohol withdrawal is not to be taken lightly as someone may exhibit extreme side effects or worse, die from this experience if not supervised. 

If you know is going through alcohol withdrawal, you might have heard about the CIWA Protocol. What is it? And how can it help patients with withdrawal symptoms?

If you are a new nurse or a nursing student who wants to learn all about CIWA protocol, this episode is for you.

Today we will learn about CIWA protocol and how to manage alcohol withdrawal. Keep watching to learn more. 

Alcohol Withdrawl Effects

Symptoms of alcohol withdrawal occur because alcohol is a central nervous system depressant. Alcohol simultaneously enhances inhibitory tone (via modulation of gamma-aminobutyric acid [GABA] activity) and inhibits excitatory tone (via modulation of excitatory amino acid activity). 

In patients with alcohol dependence, only the constant presence of ethanol preserves homeostasis. Abrupt cessation unmasks the adaptive responses to chronic ethanol use, resulting in overactivity of the central nervous system.

Alcohol stimulates GABA receptors. 

What is GABA

GABA is a type of neurotransmitter. Neurotransmitters are chemical messengers in the nervous system.

Messages travel along the nervous system via neurons that pass signals to each other. For example, they might carry a message from the brain to your hand to move away from danger, or they may carry a message from the hand to the brain saying a pot is hot.

As an inhibitory neurotransmitter, GABA blocks certain nerve transmission, known as messages. It prevents the stimulation of neurons.

This means that a neuron that receives a message along the way doesn’t act on it, so the message isn’t sent on to other neurons.

This slowdown in message transition may be helpful because GABA can specifically stop messages related to extreme moods.

In other words, GABA calms your nervous system down, helping you to not become overly anxious or afraid.

  • Gamma-aminobutyric acid — GABA is the major inhibitory neurotransmitter in the brain. Highly specific binding sites for ethanol are found on the GABA receptor complex. Chronic ethanol use induces insensitivity to GABA such that more inhibitor is required to maintain a constant inhibitory tone
  • As alcohol tolerance develops, the individual retains arousal at alcohol concentrations that would normally produce lethargy or even coma in relatively alcohol-naïve individuals. Cessation of alcohol or a reduction from chronically elevated concentrations results in decreased inhibitory tone.

Alcohol Withdraw Signs and Symptoms

Alcohol withdrawal doesn’t happen right away but it does follow a timeline so nurses know what to do during each phase. Here’s what you need to know:


6 hours after you stop drinking

Mild symptoms can start as early as 6 hours after you put down your glass. They can include:

  • Anxiety
  • Shaky hands
  • Headache
  • Nausea
  • Vomiting
  • Insomnia
  • Sweating

12-48 hours after your last drink

More serious problems, including hallucinations, can start in this timeframe and may include hallucinations (about 12-24 hours after you stop drinking) and seizures within the first 2 days after you stop. You can see, feel, or hear things that aren’t there.  

48-72 hours after you stop drinking

Delirium tremens or DTs usually start at this timeframe. These are severe symptoms that include vivid hallucinations and delusions. Only about 5% of people with alcohol withdrawal have them. Those that do may also have:

  • Seizures 
  • Hallucinations
  • Confusion
  • Racing heart
  • High blood pressure 
  • Heart palpitations 
  • Fever
  • Heavy sweating

What is the CIWA protocol? 

The Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-AR) is an instrument used by medical professionals to assess and diagnose the severity of alcohol withdrawal. The CIWA-AR is one of the most common methods of treating alcohol withdrawal

The CIWA-AR allows physicians to measure the severity of patients’ alcohol withdrawal syndrome, and thus prevent further health complications and treat the withdrawal syndrome accordingly

CIWA Scoring

The CIWA-AR scores on a scale from 0-7 for each symptom and takes less than 2 minutes to complete. By adding up the scores of each 10 symptoms into a total, physicians can determine a severity range for patients’ withdrawal syndrome.

Cumulative scores of less than 8-10 indicate mild withdrawal. Next, scores of 8-15 indicate moderate withdrawal, and scores of 15 or more 15 indicate severe withdrawal with impending possible delirium tremens.

  1. Nausea Vomiting: 0-7
    1. 0 – No nausea, no vomiting 
    2. 1 – mild nausea, no vomiting
    3. 4 – intermittent nausea and dry heaves
    4. 7 – constant nausea, frequent dry heaves, and vomiting
  2. Agitation: 0-7
    1. 0 – normal activity
    2. 1 – somewhat more than normal activity
    3. 4 – moderately fidgety and restless
    4. 7 – paces back and forth or consistently thrashes
  3. Visual disturbances: 0-7
    1. 0 – not present
    2. 1 – very mild sensitivity
    3. 2 – mild sensitivity
    4. 3 – moderate sensitivity
    5. 4 – Moderately severe hallucinations
    6. 5 – severe hallucinations
    7. 6 – extremely severe hallucinations
    8. 7 – continuous hallucinations
  4. Tremor: 0-7
    1. 0 – no tremor
    2. 1 – not visible but can be felt
    3. 4 – moderate with the patient’s arms extended
    4. 7 – severe, even with arms not extended
  5. Tactile Disturbance: 0-7
    1. 0 – none
    2. 1 – very mild itching, pins, and needles, burning, or numbness
    3. 2 – mind itching, pins, and needles, burning, or numbness
    4. 3 – moderate itching, pins, and needles, burning, or numbness
    5. 4 – moderately severe hallucinations
    6. 5 – severe hallucinations
    7. 6 – extremely severe hallucinations
    8. 7 – continuous hallucinations
  6. Headache fullness in head: 0-7
    1. 0 – not present
    2. 1 – very mild
    3. 2 – mild
    4. 3 – moderate
    5. 4 – moderately severe
    6. 5 – severe
    7. 6 – very severe
    8. 7 – extremely severe
  7. Paroxysmal sweats 0-7
    1. 0 – no sweat
    2. 1 – barely perceptible sweating, palms moist
    3. 4 – beads of sweat obvious on the forehead
    4. 7 – drenching sweats
  8. Auditory disturbances: 0-7
    1. 0 – not present
    2. 1 – very mild harshness or ability to frighten
    3. 2 – mild harshness or ability to frighten
    4. 3 – moderate harshness or ability to frighten
    5. 4 – moderately severe hallucinations
    6. 5 – severe hallucinations
    7. 6 – extremely severe hallucinations
    8. 7 – continuous hallucinations
  9. Orientation and clouding of sensorium: 0-4
    1. 0 – oriented and can do serial additions
    2. 1 – cannot do serial additions and is uncertain about dates
    3. 2 – disoriented for date by no more than 2 calendar days
    4. 3 – disoriented for date by more than 2 calendar days
    5. 4 – disoriented for place and/or person
  10. Anxiety: 0-7
    1.  0 – no anxiety at ease
    2. 1 – mildly anxious
    3. 4 – moderately anxious or guarded, so anxiety is inferred
    4. 7 – equivalent to acute panic states as seen in severe delirium or acute delirium or acute schizophrenic reaction.

The total score is a simple sum of each item score (maximum score is 67)

Score results:

  • <10: Very mild withdrawal
  • 10 to 15: Mild withdrawal
  • 16 to 20: Modest withdrawal
  • >20: Severe withdrawal

Drug Dosage

  • 5-9: Lorazepam 1mg IV q 4h
  • 10-14: Lorazepam 2mg IV q 2h
  • 15-19: lorazepam 3mg IV q 1h
  • 20-24: Lorazepam 4mg IV q30min
  • 25-29: Lorazepam 5mg IV q15min
  • 30-34: Lorazepam 6mg IV q10min

Seizure precautions

  • Reduce Environmental Stimuli
  • Pad Side Rails
  • Bed Lowest Position
  • Oxygen and Suction Available

Drug selection

Benzodiazepines are used to treat the psychomotor agitation most patients experience during withdrawal and to prevent progression from minor withdrawal symptoms to major ones. 

Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) are used most frequently to treat or prevent alcohol withdrawal, but other benzodiazepines may be used. In general, long-acting benzodiazepines with active metabolites (eg, diazepam or chlordiazepoxide) are preferred because they seem to result in a smoother clinical course with a lower chance of recurrent withdrawal or seizures.


Benzodiazepines are a type of sedative medication. This means they slow down the body and brain’s functions. These drugs increase the effects of GABA on your brain and body. It means these drugs can:

    • make you feel relaxed and sleepy (sedation)
    • reduce your anxiety
    • relax your muscles.

Dexmedetomidine (Precedex) as an adjunct treatment for severe alcohol withdrawal in the ICU:

  • Precedex belongs to a class of drugs called Sedatives.
  • Precedex may cause serious side effects including:
    • low or high blood pressure
    • slow heart rate
    • abnormal heart rate

To learn more about the CIWA protocol and how to manage withdrawal symptoms, click here 👇👇👇


00:00 Introduction
01:29 What happens to someone that goes through alcohol withdrawal?
02:53 How GABA affects the body
05:06 Alcohol affects depression and anxiety
05:50 How to deal with alcoholic patients
08:08 Families should create a safe space
09:10 Signs and symptoms of alcohol withdrawal
13:07 What is CIWA Protocol?
15:20 Intravenous (IV) over Per Oral (PO)
17:34 The CIWA Protocol Scale
21:32 Drug Dosages
23:45 Seizure precautions
24:23 Drug Selection
28:22 Physical restraints
29:54 Wrapping up the episode