Diagnostic Algorithm for Alcohol Withdrawal Syndrome
The diagnosis of AWS is clinical, based on history of alcohol cessation and presence of characteristic symptoms, NOT on CIWA scoring—CIWA is useful for severity assessment and treatment planning but should never be used as a diagnostic tool. 1
Step 1: Establish Clinical Diagnosis
Confirm recent alcohol cessation or reduction:
- AWS typically begins 6-24 hours after abrupt cessation or reduction of alcohol in patients with chronic heavy use 1
- Peak severity occurs at 3-5 days after cessation 1
Identify characteristic symptoms (need ≥2 for diagnosis):
- Autonomic hyperactivity: tachycardia, sweating, hypertension 1, 2
- Hand tremor 1
- Gastrointestinal symptoms: nausea, vomiting 1
- Psychomotor agitation 2
- Anxiety 2
- Seizures (alcohol withdrawal seizures) 1
- Hallucinations (visual, auditory, or tactile) 1
- Delirium tremens: altered mental status, disorientation to person/place/time, fluctuating symptoms 1
Step 2: Rule Out Mimicking Conditions
Critical caveat: Multiple conditions can mimic AWS and must be excluded:
- Anxiolytic/benzodiazepine withdrawal 1
- Anxiety disorders 1
- Sepsis 1
- Hepatic encephalopathy 1
- Severe pain 1
This is why CIWA cannot be used for diagnosis—high scores occur in all these conditions. 1
Step 3: Evaluate for Medical Complications
Perform comprehensive assessment for comorbidities that commonly accompany AWS:
- Dehydration and electrolyte imbalances (especially magnesium) 1
- Renal failure 1
- Head trauma 1
- Infection 1
- Gastrointestinal bleeding 1
- Pancreatitis 1
- Liver failure 1
Monitor vital signs frequently, especially in first 72 hours 1, 3
Step 4: Assess Severity Using CIWA-Ar Scale
Once diagnosis is established clinically, use CIWA-Ar to quantify severity and guide treatment intensity:
- Score >8: Moderate withdrawal requiring pharmacotherapy 3, 4, 5
- Score ≥15: Severe withdrawal requiring aggressive management 3, 4
- Use symptom-triggered regimens based on CIWA scores rather than fixed-dose schedules 3
Step 5: Risk Stratification for Severe AWS
Identify high-risk features predicting severe withdrawal or complications:
- History of delirium tremens (LR 2.9) 6
- Baseline systolic blood pressure ≥140 mmHg (LR 1.7) 6
- History of withdrawal seizures 1
- High levels of recent drinking 1
- Serious medical or psychiatric comorbidities 1
Consider using PAWSS (Prediction of Alcohol Withdrawal Severity Scale) for systematic risk assessment:
- ≥4 findings: LR 174 for severe AWS (specificity 0.93) 6
- ≤3 findings: LR 0.07 for severe AWS (sensitivity 0.99) 6
Step 6: Determine Treatment Setting
Admit for inpatient treatment if ANY of the following:
- Significant AWS with CIWA >8 1
- History of withdrawal seizures or delirium tremens 1, 4
- Serious medical comorbidities (liver failure, respiratory failure, renal failure) 1
- Serious psychiatric comorbidities 1
- Failed outpatient treatment 1
- High levels of recent drinking 1
Outpatient treatment acceptable only for mild withdrawal without risk factors 1
Critical Diagnostic Pitfalls to Avoid
Do not use CIWA as a diagnostic tool—it is for severity assessment only after clinical diagnosis is established. 1 High CIWA scores can occur in sepsis, hepatic encephalopathy, anxiety disorders, and other conditions that mimic AWS. 1
Do not miss genuine seizure disorders—alcohol withdrawal seizures are self-limited and do not require anticonvulsants, but must be distinguished from epilepsy. 1
Do not delay thiamine administration—give 100-300 mg/day to ALL patients with suspected AWS before any glucose-containing IV fluids to prevent precipitating Wernicke encephalopathy. 1, 3, 4