Alcohol Withdrawal Syndrome: Diagnosis, CIWA-Ar Scoring, and Evidence-Based Management

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Alcohol Withdrawal Syndrome: An Overlooked Medical Emergency

Alcohol Withdrawal Syndrome (AWS) is a common yet frequently under-recognized medical condition encountered in emergency departments, hospital wards, and perioperative settings across the United States. Failure to identify and treat AWS early can result in seizures, delirium tremens, prolonged hospitalization, and increased mortality.

AWS occurs after the sudden reduction or cessation of alcohol intake in individuals with chronic dependence. Long-term alcohol exposure leads to downregulation of GABA-mediated inhibition and upregulation of glutamatergic excitation. When alcohol is withdrawn, this imbalance results in autonomic hyperactivity and central nervous system excitability.

Clinical Spectrum

Symptoms typically begin 6–24 hours after the last drink and may progress through:

  • Tremor, anxiety, diaphoresis

  • Tachycardia and hypertension

  • Hallucinations and agitation

  • Seizures and delirium tremens (DTs)

Assessment and Risk Stratification

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol–Revised) scale is widely used to quantify severity and guide therapy. Scores ≥15 indicate moderate to severe withdrawal and warrant close monitoring and pharmacologic treatment.

Management Principles

  • Benzodiazepines remain first-line therapy

  • Symptom-triggered regimens reduce overtreatment when feasible

  • Thiamine must be administered before glucose to prevent Wernicke encephalopathy

  • Electrolyte abnormalities (especially magnesium and potassium) require correction

Early recognition and structured management significantly reduce complications and improve outcomes.

🎥 Watch the Full Video Explainer

For a concise, board-oriented explanation of AWS, including CIWA-Ar use and management pearls, watch the full video here:
👉 https://youtu.be/fe7CtsHcSj4



Key Takeaway

Alcohol Withdrawal Syndrome is a time-sensitive diagnosis.
Normal vital signs early in presentation do not exclude progression to severe withdrawal. Proactive screening and early treatment save lives.

References & Further Reading 

  1. ASA Monitor (2026).
    Alcohol Withdrawal Syndrome: An Overlooked Surgical Hazard.
    https://journals.lww.com/monitor/fulltext/2026/02000/alcohol_withdrawal_syndrome__an_overlooked.21.aspx

  2. National Institute on Alcohol Abuse and Alcoholism (NIAAA).
    Alcohol Withdrawal Overview.
    https://www.niaaa.nih.gov

  3. StatPearls – Alcohol Withdrawal Syndrome.
    https://www.ncbi.nlm.nih.gov/books/NBK441882/

  4. Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar).
    https://www.mdcalc.com/calc/2016/ciwa-ar-alcohol-withdrawal

  5. American Society of Addiction Medicine (ASAM) Guidelines.
    https://www.asam.org/quality-care/clinical-guidelines

  6. UpToDate.
    Alcohol withdrawal: Clinical features and management.
    https://www.uptodate.com

  7. World Health Organization (WHO).
    Management of Substance Withdrawal.
    https://www.who.int

Location: United States

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