Alcohol Withdrawal: Assessment, CIWA-Ar & Management
How to score severity accurately, prevent seizures, manage delirium tremens, and keep patients safe — NICE-aligned guide.
Alcohol withdrawal is one of the most common — and most dangerous — conditions you’ll manage on acute wards. It can progress from mild tremors to life-threatening delirium tremens (DTs) in hours. The biggest mistake? Assuming “they don’t look that bad” — or failing to ask about alcohol use in the first place. Every patient admitted should be screened for risky drinking — because withdrawal can start even if they’re admitted for something completely unrelated: a broken leg, chest infection, or heart attack.
This guide teaches you how to screen, use the CIWA-Ar tool correctly, dose medication safely, and spot the red flags that mean “act now.” Fully aligned with NICE CG115 and BNF Chapter 4.10.
1. National Guidance
All content aligned with: NICE CG115 — Alcohol-Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Dependence; BNF Chapter 4.10 — Drugs Used in Substance Dependence; Royal College of Physicians — Management of Alcohol Withdrawal Syndrome.
📎 Source: NICE CG115 — Alcohol-Use Disorders Full Guideline
⚠️ Local protocols vary. Chlordiazepoxide dosing, CIWA-Ar frequency, and seizure prophylaxis should always be checked against your trust’s alcohol withdrawal policy.
2. Who Is at Risk? — Screen Every Patient
Don’t wait for obvious signs. Use a quick screen on admission — the AUDIT-C is ideal (3 questions, takes 30 seconds):
- How often do you have a drink containing alcohol? (0=never, 1=monthly or less, 2=2–4 times/month, 3=2–3 times/week, 4=4+ times/week)
- How many standard drinks do you have on a typical day when drinking? (0=1–2, 1=3–4, 2=5–6, 3=7–9, 4=10+)
- How often do you have 6 or more drinks on one occasion? (0=never, 1=less than monthly, 2=monthly, 3=weekly, 4=daily/almost daily)
Score ≥5 (men) or ≥4 (women) = risky drinking → further assessment needed for withdrawal risk.
High-Risk Features — Red Flags for Severe Withdrawal
These patients need urgent monitoring and early medication:
- Daily alcohol intake ≥50 units (e.g., 25 pints beer, 10 large glasses wine)
- Previous history of alcohol withdrawal seizures or DTs
- Current use of benzodiazepines or other sedatives
- Co-existing conditions: liver disease, infection, head injury, acute kidney injury
- Malnutrition or electrolyte imbalance (low K⁺, low Mg²⁺)
- Withdrawal starting before admission (tremors, anxiety, sweating)
Note: 1 unit = 10ml pure alcohol → ½ pint beer (4% ABV) ≈ 1 unit; 1 small glass wine (12% ABV) ≈ 1.5 units; 1 single spirit measure ≈ 1 unit.
3. Stages of Withdrawal — What to Expect & When
Timeline is predictable but severity varies. Can escalate rapidly — don’t be lulled into thinking “it’s staying mild”:
| Timeframe | Symptoms | Severity & Action |
|---|---|---|
| 6–12 hrs after last drink | Early: tremors, anxiety, sweating, nausea, headache, insomnia, palpitations | Mild–Moderate. Start CIWA-Ar monitoring. Explain what’s happening to reduce fear. |
| 24–48 hrs peak risk for seizures | Increasing tremor, confusion, hallucinations (often visual/tactile), tachycardia, hypertension, vomiting | Moderate–Severe. CIWA-Ar every 1–2 hours. Ensure chlordiazepoxide prescribed. Seizure risk highest here. |
| 48–72 hrs peak DTs risk | Delirium Tremens in ~5%: profound confusion, agitation, fever, terrifying hallucinations, severe autonomic instability | 🔴 SEVERE. 5–15% mortality if untreated. Escalate urgently. May need ITU-level monitoring. |
| 5–7 days | Physical symptoms subside but anxiety, poor sleep, low mood can persist weeks | Continue support. Referral to addictions team. Long-term relapse prevention. |
4. CIWA-Ar — The Gold-Standard Assessment Tool
The Clinical Institute Withdrawal Assessment for Alcohol (revised) is the tool you will use on every shift. 10 items, each scored 0–7 (except orientation 0–4). Max score = 67. It guides EVERY dose decision — never guess, always score.
| Item | What to Assess | 0 = None → 7 = Worst Possible |
|---|---|---|
| Nausea/Vomiting | Ask + observe. 0=no nausea → 7=constant severe vomiting | Important: score what you SEE, not just what they say |
| Tactile Disturbances | Itching, pins/needles, burning, numbness, “bugs crawling on skin” | Early hallucinatory sign — don’t dismiss as anxiety |
| Auditory Disturbances | Sounds, voices, whispers not there. 0=none → 7=continuous terrifying voices | Ask: “Are you hearing anything others can’t hear?” |
| Visual Disturbances | Flashes, shapes, faces, lights. 0=clear → 7=can’t distinguish reality | Check in good light — dilated pupils common too |
| Tremor | Arms extended, fingers spread. 0=no tremor → 7=severe even at rest | Check hands OUTSTRETCHED — rest tremor = more advanced |
| Agitation | Restlessness, pacing, unable to sit. 0=calm → 7=thrashing, out of control | Observe during conversation — can they stay seated? |
| Paroxysmal Sweats | Clammy forehead → soaking sheets. 0=none → 7=drenching sweats | Feel chest/forehead — not just room temperature |
| Anxiety | Nervousness, dread, panic. 0=relaxed → 7=overwhelming terror | Ask: “On a scale 0–10, how anxious are you right now?” |
| Headache / Fullness in Head | Pressure, band-like pain. 0=absent → 7=worst ever, can’t think | Check BP — severe headache may also indicate hypertension |
| Orientation & Clouding of Sensorium | Time, place, person. 0=fully oriented → 4=disoriented ×3 | Ask date, month, year, where they are, why here. See delirium vs confusion |
What the Score Means — Action Guide
- 0–9 = Minimal — No PRN needed. Reassess 4-hourly. If stable <9 for 72hrs → stop scoring
- 10–18 = Moderate — Give PRN dose. Reassess in 2 HOURS. If consistently >10 → review regular dose
- 19–21 = Severe — Give higher PRN. Reassess in 30–60 MINUTES. Inform senior nurse/doctor
- >21 = Critical — Immediate medical review. Risk of DTs/seizure. Monitor NEWS2 closely
5. Medication — Chlordiazepoxide & Regimens
Long-acting benzodiazepines are first-line — they provide smooth cover and less breakthrough withdrawal. Chlordiazepoxide is standard in UK trusts. Lorazepam is the alternative in liver impairment or elderly patients.
| Regimen Type | How It Works | Notes |
|---|---|---|
| Fixed-Reduction (Standard) | Set dose reducing over 7–10 days regardless of symptoms. e.g., 30mg QDS → 20mg QDS → 15mg QDS → stop | Simple, consistent. Good for high-risk where missed scoring could cause harm. Risk: over-sedation or breakthrough |
| Symptom-Triggered (CIWA-Led) | NO fixed dose. Only give when CIWA-Ar ≥8–10. Titrates to actual need automatically | Preferred where staff trained in CIWA. Shorter total treatment duration. Requires consistent skilled assessment |
| Mixed / Local Protocol | Base regular dose + CIWA-triggered PRN breakthrough cover. Most common UK approach | Safest balance. Base dose prevents crashes; PRN responds to spikes. Follow YOUR trust’s chart exactly |
Dosing Principles — Memorise These
- Standard chlordiazepoxide: Start 10–30mg QDS PO (max 40mg single dose). Reduce over 7–10 days. Elderly/liver impairment: halve dose, use lorazepam instead
- PRN dose example: CIWA 10–18 → 10–20mg; CIWA 19–21 → 20–40mg. Never stack doses faster than trust interval (usually min 2 hours apart)
- Lorazepam alternative: 0.5–2mg QDS ± PRN. Shorter half-life → less accumulation but need MORE frequent monitoring. Use if eGFR low, liver cirrhosis, or >65yrs frail
- Never stop abruptly: Rapid discontinuation = withdrawal seizures. Even short courses need tapering
6. Complications — Seizures, DTs & Wernicke’s
Alcohol Withdrawal Seizures
- Peak: 12–48hrs post-last drink
- Generalised tonic-clonic, usually single/short-lived — but can cluster → status epilepticus
- Management: ABC, protect airway, do NOT insert anything in mouth. IV lorazepam 4mg stat if prolonged. Follow acute seizure protocol
- Prophylaxis: Ensure chlordiazepoxide cover is adequate — history of previous seizure = higher starting dose needed
- Investigate: Check glucose, electrolytes, exclude head injury — not every fit is “just withdrawal”
Delirium Tremens (DTs)
| Feature | What You’ll See | Immediate Action |
|---|---|---|
| Conscious level | Fluctuating confusion → fear, paranoia, inability to focus | Reorient repeatedly. Calm consistent environment. Low lighting at night |
| Autonomic storm | HR >120, BP >180/100, temp >38°C, drenching sweats | Monitor NEWS every 15–30 mins. IV fluids — dehydration worsens confusion |
| Hallucinations | Visual/tactile — “bugs, snakes, faces”. Terrifying, vivid | Do NOT reinforce them — “I can’t see that but I know it feels real”. Stay with them — safety risk |
| Medical emergency | Mortality 5–15% untreated | Senior review URGENT. Higher/extra benzodiazepines. May need ICU/HDU |
Wernicke’s Encephalopathy — Preventable but Deadly
Thiamine (Vitamin B1) deficiency from poor nutrition. Alcohol blocks absorption and depletes stores. Can look identical to withdrawal — confusion, ataxia, eye signs. Miss it → permanent brain damage or death (Korsakoff’s syndrome).
- Classic triad: Confusion + Ataxia + Ophthalmoplegia (nystagmus, gaze palsy) — BUT only fully present in ~10% cases. High index of suspicion = treat first, confirm later
- Who needs it: EVERY patient undergoing alcohol detox. Pabrinex IV high potency first, then oral maintenance
- Dose timing: Give BEFORE glucose-containing fluids — glucose can precipitate acute deterioration in uncorrected deficiency
- Duration: IV Pabrinex × 5 days typically. Oral thiamine continuation for weeks–months
📎 Source: NICE CG115 — Wernicke’s & Thiamine Guidance
7. Essential Support — Fluids, Nutrition & Environment
Medication alone isn’t enough — these make detox safe and comfortable:
- Hydration: Oral preferred — small frequent sips. IV 0.9% saline if vomiting/dehydrated. Monitor fluid balance — beware excess in cardiac patients
- Nutrition: High calorie, high protein, vitamin-rich. Small frequent meals if nauseous. Thiamine + B complex + folate routine
- Environment: Same consistent staff where possible. Quiet, dim lighting at night. Familiarise — clocks, calendars, orientation boards. Minimise room changes. Family support encouraged
- Sleep hygiene: Day/night cycle maintained. Noise minimised overnight. Sedation helps but isn’t substitute for restful environment
8. Discharge & Relapse Prevention
Detox is just removing the alcohol — staying stopped is the hard part. Your handover sets them up:
- Referral to local addictions team BEFORE discharge — not a “maybe”
- Offer counselling/CBT — address underlying triggers
- Consider acamprosate — reduces craving, maintains abstinence. Start post-withdrawal once stable
- Check liver function — baseline + monitor. Alcoholic hepatitis can complicate recovery
- Provide clear contact numbers — who to call if struggling. Crisis plan in writing
- Next GP appointment booked before leaving — continuity matters