Interactive Pilot — 2026

CIWA Protocol

Master alcohol withdrawal recognition & management

This isn't a lecture — it's hands-on practice. You'll score patients, make clinical decisions, and get instant feedback as you learn.

⏱ ~30 minutes · 4 modules · Earn XP as you go

🧠

Module 1

Why withdrawal happens

📋

Module 2

CIWA-Ar scoring

💊

Module 3

Management & meds

🏥

Module 4

Bedside simulation

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Module 1

Why Withdrawal Happens

📊 The Numbers

50% of patients with alcohol use disorder will experience some withdrawal on cessation.

3–5% of those develop seizures or delirium tremens — which can be fatal.

Jesse et al., 2017

💡 Think of it this way

Alcohol is a brake pedal on the brain. With daily heavy use, the brain compensates by slamming the gas pedal (glutamate) harder and harder.

When you suddenly remove the brake (stop alcohol), the gas pedal is still floored — the brain goes into a dangerous excitatory overdrive.

🔬 The Two Players

GABA (the brake) → Inhibitory. Chronic alcohol enhances it, so the brain downregulates GABA receptors.

Glutamate (the gas) → Excitatory. Alcohol suppresses it, so the brain upregulates glutamate receptors.

⚡ Remove alcohol and you get:

Reduced brakes (↓ GABA) + floored gas (↑ glutamate) = tremor, agitation, tachycardia, hypertension, seizures.

⏱

Module 1

The Withdrawal Timeline

Tap each stage to learn more ↓

6–12 hours

Minor Withdrawal

Anxiety, tremor, insomnia, sweating, nausea

The earliest signs. Patients may appear anxious and restless. Vital signs often show mild tachycardia. Don't dismiss "I just feel off" — this is where assessment starts.

12–24 hours

Alcoholic Hallucinosis

Visual, auditory, or tactile hallucinations

Key difference from DTs: the patient usually knows the hallucinations aren't real and remains oriented. Still alarming — and a sign that escalation may be coming.

24–48 hours

Withdrawal Seizures

Generalized tonic-clonic seizures

Usually brief and self-limiting, but risk of status epilepticus exists. Seizure precautions should already be in place by this point. A seizure in withdrawal is a red flag for possible DTs ahead.

48–72 hours (peak danger)

Delirium Tremens

Confusion, agitation, autonomic storm, fever

The most dangerous stage. Mortality: 1–5% with treatment, up to 37% without. Profound confusion (not oriented), global tremor, tachycardia, hypertension, fever, drenching sweats. This is an ICU-level emergency.

🔥 The Kindling Effect

Each withdrawal episode can be worse than the last. The brain becomes permanently sensitized. A patient on their 3rd withdrawal may seize when their 1st episode was mild.

Always ask: "Have you ever gone through withdrawal before?"

⚡ Quick Check — How Fast Can You Match?

DTs

Seizures

Minor Withdrawal

Hallucinosis

6–12 hours: anxiety, tremor, sweating

48–72 hours: confusion, autonomic storm

12–24 hours: sees/hears things, stays oriented

24–48 hours: generalized tonic-clonic

📋

Module 2

The CIWA-Ar: Your Scoring Tool

🎯 What Is It?

The Clinical Institute Withdrawal Assessment for Alcohol, Revised — the gold-standard bedside tool for measuring withdrawal severity.

10 domains · Max score: 67 · Takes 2–5 minutes

Sullivan et al., 1989 · Validated across multiple settings

Why this changed everything

📊 Before vs. After CIWA-Ar

Before: Everyone got the same benzo schedule → over-sedation for some, under-treatment for others.

After (symptom-triggered therapy): Medicate only when the CIWA score says to → 50–70% less medication, treatment time from 68 hours → 9 hours.

The 10 Domains at a Glance

#	Domain	Range	Ask / Observe
1	Nausea	0–7	"Do you feel sick to your stomach?"
2	Tremor	0–7	Arms out, fingers spread — observe
3	Sweats	0–7	Touch forehead/palms — observe
4	Anxiety	0–7	"Do you feel nervous?" Watch for fidgeting
5	Agitation	0–7	Observe behavior: calm → thrashing
6	Tactile	0–7	"Any itching, burning, bugs crawling?"
7	Auditory	0–7	"Are sounds harsh? Hearing things?"
8	Visual	0–7	"Light too bright? Seeing things?"
9	Headache	0–7	"Band around head?" (NOT dizziness!)
10	Orientation	0–4	"What day? Where are you? Who am I?"

⚠️ Common Pitfall

Headache ≠ Dizziness. The CIWA headache item measures head fullness or band-like pressure. If a patient says "I feel dizzy," that is not scored. Ask: "Does it feel like something is pressing on your head?"

🎯

Module 2

What the Score Means

0–9

Mild

Monitor q4–8h. Supportive care only. Hydration, thiamine, quiet room.

10–18

Moderate

Medicate per protocol. Reassess q1–2h. Consider closer monitoring.

19–67

Severe

Medicate + notify MD. Reassess q30–60min. Consider ICU.

🏆 6 Rules for Accurate Scoring

1. Build rapport first — no one cooperates if they feel judged

2. Use the exact phrasing — it's validated

3. Observe before you ask (tremor, sweats, agitation)

4. Score what you see right now, not an hour ago

5. Document each domain, not just the total

6. Patient must be able to participate — if not, use RASS and call the provider

⚡ Decision Point

Your patient has a CIWA of 14. They're anxious, mildly tremulous, and sweating. What's your move?

A Continue monitoring — only medicate at 19+

B Administer lorazepam 1–2 mg per protocol, reassess in 1–2 hours

C Call a rapid response

🩺

Module 2 — Hands-On

CIWA Bedside Simulator

Use the sliders to score each domain based on the patient presentation. Watch the total update in real time.

Patient: Mr. J, 52 y/o, admitted for cellulitis. Reports drinking "a pint of vodka daily." Last drink ~16 hours ago.

HR 102

BP 158/94

Temp 99.4°F

RR 20

1. Nausea/Vomiting

He says "my stomach is a bit queasy" but hasn't vomited.

0

2. Tremor

You ask him to extend his arms — you see a visible, moderate tremor.

0

3. Paroxysmal Sweats

His forehead is beaded with sweat, palms are moist.

0

4. Anxiety

He says "I feel really on edge." He's fidgeting with the blanket.

0

5. Agitation

Moderately restless — shifting positions frequently, picking at IV site.

0

6. Tactile Disturbances

"My skin feels kind of tingly." No reports of bugs or burning.

0

7. Auditory Disturbances

"Sounds seem a little louder." Not hearing voices.

0

8. Visual Disturbances

"The light is kind of bothering me." No hallucinations.

0

9. Headache

"A little bit, like a band around my head."

0

10. Orientation

Knows the date, location, and your role. Oriented ×3.

0

Score the patient above

💊

Module 3

Managing Withdrawal

Landmark Evidence

📊 Symptom-Triggered vs. Fixed Dose

The Saitz et al. (1994) trial in JAMA changed everything:

9 hrs

Symptom-triggered avg treatment

68 hrs

Fixed-dose avg treatment

Bottom line: Medicate based on the CIWA score, not the clock. Less medication, shorter stays, fewer ICU transfers.

💊 Quick Med Reference

CIWA	Medication	Action
< 10	None	Monitor q4–8h, thiamine, supportive care
10–18	Lorazepam 1–2 mg or Chlordiazepoxide 25–50 mg PO	Administer, reassess q1–2h
≥ 19	Lorazepam 2–4 mg IV may repeat per protocol	Notify MD, reassess q30–60min, consider ICU

💊 Liver Matters

Lorazepam → Safe in liver disease (no hepatic oxidation needed)

Chlordiazepoxide → Smoother taper, but needs a working liver

🛡️

Module 3

Nursing Essentials & Red Flags

🚨 Thiamine Rule — Memorize This

Thiamine BEFORE glucose. Always. No exceptions.

Glucose burns through thiamine. In a depleted patient, giving glucose first can trigger Wernicke encephalopathy — confusion, ataxia, ophthalmoplegia. Permanent brain damage if missed.

🏥 Your Bedside Checklist

✅ Vitals q1–4h based on severity (include temp!)

✅ Continuous telemetry if CIWA ≥ 19 or cardiac hx

✅ I&O — these patients dehydrate fast

✅ Quiet, well-lit room. Minimize stimulation.

✅ Reorientation: clock, whiteboard, consistent staff

✅ Seizure precautions: bed low, rails padded, suction ready

✅ 1:1 if hallucinating, agitated, or CIWA ≥ 25

✅ Fall risk interventions (tremor + sedating meds = falls)

🚩 Call the Provider RIGHT NOW if:

🔴 CIWA ≥ 20 or scores climbing fast despite meds

🔴 Seizure activity

🔴 Temp > 101°F (DTs? Infection?)

🔴 HR > 120 or BP > 180/__ or < 90/__

🔴 Acute mental status change

🔴 > 3 doses lorazepam in 1 hour, no improvement

🔴 RR < 10 or SpO₂ < 92% (respiratory depression)

🔴 Patient can no longer participate in CIWA

⚡ Decision Point

A patient with known cirrhosis is starting to withdraw. The resident asks your recommendation for a benzo. What do you say?

A Diazepam — longest acting, best coverage

B Chlordiazepoxide — smoothest taper

C Lorazepam — doesn't require hepatic oxidation

The nurse before you gave D5W and a meal tray, but hasn't given thiamine yet. What's your priority?

A No big deal — give thiamine with the next med pass

B Give thiamine 100 mg IV/IM immediately — glucose was already given

C Stop the D5W and wait for a provider order

✅

Module 3 — Quick Check

Test Yourself

1. STT is better than fixed-dose because:

A Requires less nursing assessment

B Less total benzo, shorter treatment, fewer ICU transfers

C Eliminates need for CIWA monitoring

2. A patient's CIWA jumps from 12 to 24 in two hours, they're febrile at 101.5°F, HR 124. What's your FIRST action?

A Administer lorazepam and reassess in 2 hours

B Notify provider immediately — multiple red flags

C Apply ice packs for the fever and continue monitoring

🏥

Module 4

Case A: Mr. Thompson

Robert Thompson, 54 y/o — Admitted for acute pancreatitis.
10–12 beers daily × 20 years. Last drink 14 hours ago. 1 prior withdrawal episode (no seizures). Alert, oriented, cooperative but anxious.

HR 96

BP 148/88

Temp 98.9°F

Your CIWA-Ar result: Nausea 2, Tremor 3, Sweats 3, Anxiety 3, Agitation 2, Tactile 0, Auditory 1, Visual 0, Headache 1, Orientation 0 = Total: 15 (Moderate)

What's your immediate nursing action?

A Continue monitoring only — save meds for CIWA ≥ 19

B Lorazepam 1–2 mg per protocol, reassess in 1–2 hours

C Call rapid response — this patient had prior withdrawal

What about his history makes you especially vigilant?

A His age — older patients always do worse

B His pancreatitis — GI issues complicate scoring

C Prior withdrawal episode — kindling means this one could be worse

🚨

Module 4 — Critical Case

Case B: Ms. Garcia

Maria Garcia, 68 y/o — Post-op day 1 hip replacement.
Chart says "social drinker." Family reveals: bottle of wine nightly × decades.
36 hours since last drink. Pulling at IV lines, crying out, terrified.

HR 118

BP 172/98

Temp 100.8°F

RR 22

Your CIWA-Ar: Nausea 5, Tremor 6, Sweats 6, Anxiety 6, Agitation 6, Tactile 5, Auditory 5, Visual 5, Headache 0, Orientation 4 = Total: 48 (Severe)

This is a medical emergency. What is your FIRST action?

A Administer lorazepam 1 mg PO and reassess in 2 hours

B Call provider / rapid response, lorazepam 2–4 mg IV, seizure precautions, 1:1

C Apply restraints first for safety, then call the provider

How could better screening have prevented this crisis?

A "Social drinker" was adequate — this was unpredictable

B An AUDIT-C screening at pre-op would have identified true use and triggered prophylaxis

C Blood alcohol on admission would have caught it

🏆

Final Assessment

Show What You Know

8 questions. Score ≥ 75% for competency readiness. Good luck!

1. AWS is caused by:

A Serotonin depletion

B GABA↓ + Glutamate↑ = excitatory surge

C Dopamine toxicity

2. Max CIWA-Ar score?

A 50

B 67

C 70

3. DTs peak at:

A 12–24 hours

B 24–48 hours

C 48–72 hours

4. Preferred benzo in liver disease?

A Chlordiazepoxide

B Lorazepam

C Diazepam

5. Thiamine before glucose prevents:

A Korsakoff syndrome

B Wernicke encephalopathy

C Hepatic encephalopathy

6. CIWA of 22 = ?

A Mild — monitor only

B Moderate — medicate, reassess q1–2h

C Severe — medicate, notify MD, reassess q30–60min

7. Kindling means:

A First withdrawal is always the worst

B Each withdrawal episode can be more severe

C Benzos lose effectiveness over time

8. STT advantage over fixed-dose:

A Less nursing work

B Less total benzo, shorter treatment

C No monitoring needed

🎓

Course Complete!

You earned 0 XP. Well done.

📋 Next Steps

1. Submit your final assessment score to your unit educator

2. Complete a live CIWA-Ar return demonstration

3. Apply these skills at the bedside — your knowledge saves lives

📚 References

ASAM (2020). Clinical Practice Guideline on Alcohol Withdrawal Management.

Saitz et al. (1994). JAMA, 272(7), 519–523.

Sullivan et al. (1989). Br J Addiction, 84(11), 1353–1357.

Jesse et al. (2017). Acta Neurol Scand, 135(1), 4–16.

Daeppen et al. (2002). Arch Intern Med, 162(10), 1117–1121.

Olek Health Nursing Education · Pilot 2026