Alcohol Withdrawal and CIWA on the NCLEX
Withdrawal timeline, CIWA scoring, benzodiazepines, thiamine before glucose.
Alcohol withdrawal can kill. The NCLEX tests the timeline and the two drugs that prevent death.
Timeline after last drink
6-12 hours: tremors, anxiety, sweating, tachycardia, nausea. 12-24 hours: alcoholic hallucinosis (usually visual, patient knows they are not real). 24-48 hours: withdrawal seizures, generalized tonic-clonic. 48-72 hours: delirium tremens (DTs): disorientation, severe autonomic instability, fever, hallucinations the patient believes. Mortality risk if untreated.
CIWA-Ar basics
10-item symptom scale: nausea, tremor, sweats, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation. Score below 10 = mild. Symptom-triggered protocols typically medicate at 8-10 or higher. Reassess on a schedule, not once.
Benzodiazepines
First-line for withdrawal: chlordiazepoxide, diazepam, or lorazepam. Lorazepam preferred in liver disease (no active metabolites). Benzos raise the seizure threshold and treat autonomic symptoms. Taper or symptom-triggered dosing per CIWA.
Thiamine before glucose
Chronic alcohol use depletes thiamine. Giving dextrose before thiamine can precipitate Wernicke encephalopathy (confusion, ataxia, ophthalmoplegia). Give thiamine first or together with glucose, never glucose alone. Add folate and multivitamins.
Frequently asked
Hallucinosis vs DTs?
Hallucinosis: 12-24h, sensorium clear, patient can test reality. DTs: 48-72h, global confusion, unstable vitals. DTs is the emergency.
Seatbelt question: seizure precautions?
Yes, from admission. Padded rails, suction and oxygen at bedside, nothing forced in the mouth.
Why not just fluids and watching?
Untreated severe withdrawal progresses to seizures and DTs. CIWA-guided benzos are the standard.
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