Alcohol Withdrawal Syndrome: Improving Outcomes in the Emergency Department With Aggressive Management Strategies - Pharmacology EXTRA Supplement - (Pharmacology CME) | Calculated Decisions

Alcohol Withdrawal Syndrome: Improving Outcomes in the Emergency Department With Aggressive Management Strategies - Pharmacology EXTRA Supplement - (Pharmacology CME)

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The Clinical Institute Withdrawal Assessment for Alcohol, revised scale for alcohol withdrawal score objectifies alcohol withdrawal severity to help guide therapy. The Richmond Agitation and Sedation Scale ranks agitation and possibility for sedation.

Table of Contents
  1. CIWA-Ar for Alcohol Withdrawal
  2. Richmond Agitation-Sedation Scale (RASS)

CIWA-Ar for Alcohol Withdrawal


The Clinical Institute Withdrawal Assessment for Alcohol, revised scale for alcohol withdrawal score objectifies alcohol withdrawal severity to help guide therapy.

About the Score

The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale provides an efficient and objective means of assessing alcohol withdrawal that can then be utilized in treatment protocols. The CIWA-Ar can be used for patients for whom there is clinical concern for alcohol withdrawal in a variety of settings, including outpatient, emergency, psychiatric, and general medical-surgical units. It is important to note that the CIWA-Ar cannot be used effectively in patients who are intubated and sedated; a sedation scale such as the Richmond Agitation-Sedation Scale would be more appropriate in that setting.

Patients frequently underreport alcohol use, and clinicians often overlook alcohol problems in patients (Kitchens 1994). It is estimated that 1 out of 5 patients admitted to a hospital abuses alcohol (Schuckit 2001). Unrecognized alcohol withdrawal can lead to potentially life-threatening consequences including seizures and delirium tremens.

For a given individual, there is no absolute relationship between alcohol use pattern and risk of physiologic dependence or withdrawal. In general, any suspicion of daily alcohol use over several weeks or more, regardless of quantity, should raise concern for potential alcohol withdrawal. Additional variables that may contribute to risk include age, medical comorbidities (eg, hepatic dysfunction), concomitant medication use, and low seizure threshold (Roffman 2006).

It is important to note that other conditions can mimic or coexist with alcohol withdrawal, including drug overdose, trauma (eg, intracranial hemorrhage), infection (eg, meningitis), metabolic derangements, hepatic failure, and gastrointestinal bleeding. Clinicians should consider additional testing to rule out alternative diagnoses, especially if presentation includes altered mental status and/or fever.

Assessment protocols utilizing the CIWA-Ar scale vary and include medication dosing triggered by symptoms only and combined symptom-triggered and fixed-dose medication dosing.

Benzodiazepines are generally used to control psychomotor agitation and prevent progression to more severe withdrawal. Diazepam, lorazepam, and chlordiazepoxide are the most frequently used benzodiazepines. Clinicians should follow their hospital's alcohol withdrawal protocol; frequently, treatment begins with benzodiazepines when CIWA-Ar scale scores reach 8 to 10, with standing or as-needed dosing for scores of 10 to 20. Some protocols include transfer to the intensive care unit for scores >20. Clinicians should consider additional supportive care, including intravenous fluids, nutritional supplementation, and frequent clinical reassessment including vital signs.

Calculator Review Authors

Jonathan Avery, MD

Department of Addiction Psychiatry, Weill Cornell
Medicine, New York, NY

Katherine E. Taylor, MD

Department of Psychiatry, NYU Grossman School of
Medicine, New York, NY

Evidence Appraisal

Multiple randomized trials and observational studies support the use of symptom-triggered treatment (using CIWA-Ar) over fixed-schedule treatment (in which benzodiazepines are given at fixed intervals) or vitals-triggered treatment. Superior clinical endpoints include:

  • Decreased frequency of oversedation in patients with milder alcohol withdrawal
  • Decreased frequency of under-treatment in patients with greater severity of withdrawal
  • Shorter periods of hospitalization
  • Lower incidence of delirium tremens (Wartenburg 1990, Saitz 1994, Mayo-Smith 1997, Reoux 2000, Jaeger 2001, Nuss 2004)

There is also some evidence for combined symptom-triggered and fixed-schedule treatment utilizing the CIWA-Ar scale (Daeppen 2002).

The original Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) scale, published by Shaw et al in 1981, was developed to assess the severity of alcohol withdrawal, both to monitor response to treatment and for use in research. The CIWA-Ar scale developed by Sullivan et al (1989) eliminated several redundant and ineffective items to increase the scale’s efficiency while retaining clinical usefulness, validity and reliability. The study proposed using the CIWA-Ar scale as a shortened version of the original CIWA-A scale.

Reoux and colleagues compared routine hospital alcohol detoxification practice with the CIWA-Ar-based as-needed protocol in a retrospective chart review and found fewer total chlordiazepoxide milligram equivalents were used over a shorter duration with utilization of the CIWA-Ar scale.

Calculator Creator

Edward M. Sellers, MD


Original/Primary Reference

  • Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assess-ment for alcohol scale (CIWA-Ar). Br J Addict. 1989;84(11):1353- 1357. DOI: 10.1111/j.1360-0443.1989.tb00737.x

Validation References

  • Reoux JP, Miller K. Routine hospital alcohol detoxification practice compared to symptom triggered management with an Objective Withdrawal Scale (CIWA-Ar). Am J Addict. 2000;9:135-144. DOI: 10.1080/10550490050173208

Additional References

  • Shaw JM, Kolesar GS, Sellers EM, et al. Development of optimal treatment tactics for alcohol withdrawal. I. Assessment and effectiveness of supportive care. J Clin Psychopharmacol. 1981;1(6):382-389. DOI: 10.1097/00004714-198111000-00006
  • Wartenberg AA, Nirenberg TD, Liepman MR, et al. Detoxification of alcoholics: improving care by symptom-triggered sedation. Alcohol Clin Exp Res. 1990;14(1):71-75. DOI: 10.1111/j.1530-0277.1990.tb00449.x
  • Kitchens JM. Does this patient have an alcohol problem? JAMA. 1994;272(22):1782-1787. DOI: 10.1001/jama.1994.03520070039035
  • Bird RD, Makela EH. Alcohol withdrawal: what is the benzodiazepine of choice? Ann Pharmacother. 1994;28(1):67-71. DOI: 10.1177/106002809402800114
  • Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. 1997;278(2):144-151. DOI: 10.1001/jama.1997.03550020076042
  • Saitz R, Mayo-Smith MF, Roberts MS, et al. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA. 1994;272(7):519-523. DOI: 10.1001/jama.1994.03520070039035
  • Schuckit M. Alcohol and alcoholism. In: Brunwald E, Fauci AS, Kasper DL, et al. Harrison’s Principles of Internal Medicine. Vol. 2. 15th ed. New York, NY: McGraw-Hill Professional Publishing; 2001:2561-2566.
  • Jaeger TM, Lohr RH, Pankratz VS. Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients. Mayo Clin Proc. 2001;76(7):695-701. DOI: 10.4065/76.7.695
  • Daeppen JB, Gache P, Landry U, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. 2002;162(10):1117-1121. DOI: 10.4065/76.7.695
  • Nuss MA, Elnicki DM, Dunsworth TS, et al. Utilizing CIWA-Ar to assess use of benzodiazepines in patients vulnerable to alcohol withdrawal syndrome. W V Med J. 2004;100(1):21-25.
  • Roffman JL, Stern TA. Alcohol withdrawal in the setting of elevated blood alcohol levels. J Clin Psychiatry. 2006;8(3):170-173. DOI: 10.4088/pcc.v08n0307
  • Ng K, Dahri K, Chow I, et al. Evaluation of an alcohol withdrawal protocol and a preprinted order set at a tertiary care hospital. Can J Hosp Pharm. 2011;64(6):436-445. DOI: 10.4212/cjhp.v64i6.1085

Richmond Agitation-Sedation Scale (RASS)


The Richmond Agitation and Sedation Scale ranks agitation and possibility for sedation.

About the Score

The Richmond Agitation-Sedation Scale (RASS) is a validated and reliable method to assess patients’ levels of sedation in the intensive care unit (ICU). The RASS is different than the levels of sedation/ analgesia used by the American Society of Anesthesia (minimal, moderate, deep, general), and the two should not be used interchangeably.

As opposed to the Glasgow Coma Scale, the RASS is not limited to patients with intracranial processes. The RASS can be used in all hospitalized patients to describe their level of alertness or agitation. However, it is mostly used in mechanically ventilated patients in order to avoid over- and undersedation. A RASS score of -2 to 0 has been advocated in this patient population in order to minimize sedation. This strategy has been shown to reduce mortality, and to decrease the duration of mechanical ventilation and the length of stay in the ICU.

Mechanically ventilated patients who are deeply sedated (RASS scores of ≤ -3) have been shown to remain intubated and mechanically ventilated for longer periods of time. This in turn leads to longer ICU stays and higher mortality. Similarly, mechanically ventilated patients who are too agitated are at risk of self-extubation and ventilator dyssynchrony.

Patients with a RASS score ≤-3 should have their sedation decreased or modified in order to achieve a RASS of -2 to 0. Patients with a RASS score of 2 to 4 are not sedated enough and should be assessed for pain, anxiety, or delirium. The un-derlying etiology of the agitation should be investigated and appropriately treated to achieve a RASS score of -2 to 0.

A RASS score should be obtained for all hospitalized patients and at regular intervals in all mechanically ventilated patients. Unless a patient meets indications for deep sedation, a protocol for minimal sedation (RASS -2 to 0) should be used.

Calculator Review Authors

Kamal Medlej, MD

Department of Emergency Medicine, Massachusetts
General Hospital, Boston, MA

Evidence Appraisal

The interrater reliability of the RASS was demonstrated in a single-center ICU population in 2 phases: before and after implementation of the RASS. In the second phase of the study, the scale was shown to have good interrater reliability (k = 0.80) among trained nurses. This single-center study prospectively assessed the inter-rater reliability of RASS in a medical ICU population. An excellent interrater reliability (k = 0.91) was again demonstrated among nurses.

Calculator Creator

Curtis Sessler, MD


Original/Primary Reference

  • Sessler CN, Grap MJ, Brophy GM. Multidisciplinary management of sedation and analgesia in critical care. Semin Respir Crit Care Med. 2001;22(2):211-226. DOI: 10.1055/s-2001-13834

Validation References

  • Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: the reliability and validity of the Richmond Agitation Sedation Scale (RASS). JAMA. 2003;289(22):2983-2991. DOI: 10.1001/jama.289.22.2983
  • Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338-1344. DOI: 10.1164/rccm.2107138
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Publication Information

Joseph Yanta, MD, FACEP; Greg Swartzentruber, MD; Anthony Pizon, MD, FACMT

Peer Reviewed By

Gillian Beauchamp, MD, FASAM

Publication Date

March 15, 2021

CME Expiration Date

March 15, 2024    CME Information

CME Credits

4 AMA PRA Category 1 Credits.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Pharmacology CME credits, subject to your state and institutional approval.

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