Prevention and Treatment of Wernicke-Korsakoff Syndrome

1. The Problem

WKS is a relatively common potentially lethal condition, due to thiamine deficiency but reversible if treated early. WKS can also have major long-term consequences, with patients requiring permanent institutional care.  It is commonest in heavy drinkers who have a poor diet. Such patients may be unpopular with A&E staff if unkempt, drunk or abusive. Most alcohol dependent patients presenting to A&E will spontaneously leave on sobering up.  The common signs of WKS – confusion, ataxia and varying levels of impaired consciousness  – are difficult or impossible to differentiate from drunkenness.  The eye signs (ophthalmoplegia/nystagmus) are present in only 29% of cases.  Because of this, WKS may go unrecognised if not considered, e.g. for the affluent or elderly.Heavy drinkers presenting to A&E - often collapsed and/or with a head injury - require repeated neurological assessment.The intoxicated patient who does not recover fully and spontaneously may be suffering from WKS. Only if such a patient is admitted will full assessment be possible and further treatment be practical.There is no simple test to determine patients at risk of WKS.

2. The Answer

To prevent the development of, and to treat symptoms of, WKS by administration of parenteral B complex vitamins.

3. Treatment

The only available intravenous (i.v.) treatment which includes thiamine (B1), riboflavin (B2), pyridoxine (B6), and nicotinamide is Pabrinex .  The intramuscular Pabrinex preparation includes benzyl alcohol as a local anaesthetic.Two pairs of vials of Pabrinex 1 and 2 diluted in 100ml of crystalloid should be given i.v. over 30 minutes initially (anaphylaxis is rare) in A&E stat (see 4.).  If patient admitted consider 2 pairs of vials t.d.s. for 2 days IV to followed, if any improvement, by 1 pair per day for 5 days (IV or IM) at the discretion of the admitting team (mandatory for any patient with evidence of WKS when sober). Oral treatment of WKS is ineffective even if such patients comply.

4. Who to Treat

All patients with any evidence of chronic alcohol misuse and any of the following:  acute confusion, decreased conscious level, ataxia, ophthalmoplegia, memory disturbance, hypothermia with hypotension, when initially seen in A&E (may well be drunk but still treat, see 3).  Patients with delirium tremens may often also have WKS.  All of these patients should be presumed to have WKS and be considered for admission. All hypoglycaemic patients (who are treated with i.v. glucose) with evidence of chronic alcohol ingestion must be given i.v. Pabrinex immediately because of the risk of acutely precipitating WKS.

5. Follow-up

All such patients should be offered support for reducing alcohol dependence, e.g. referral to an Alcohol Health Worker.
If the patient is admitted, e.g. to detoxify or for delirium tremens, it will be possible to distinguish signs of WKS from those of drunkenness

6. References:

• Touquet R, Fothergill J, Henry JA, Harris NH (2000): Accident and emergency medicine. Chap. 29. In: Clinical negligence. 3rd ed., Eds: Powers,MJ; Harris,NH, Butterworths, London, p989-1037. (see para 29.103).
• Royal College of Physicians of London.  Alcohol – can the NHS afford it?  Recommendations for a coherent alcohol strategy for hospitals.  February 2001; appendix 3, p49.
• Thomson AD, Cook CCH, Touquet R, Henry JA.  The Royal College of Physicians report on Alcohol: Guidelines for managing Wernicke’s Encephalopathy in the A&E Department. Alcohol & Alcoholism 2002; 37, 513-521.
• Paton A, Touquet R,  Eds  ABC of Alcohol, 4th Edition, March 2005, BMJ Books, Blackwell Publishing.