Background
Alcohol misuse is a major cause of ED attendance.
Treatment of WE is 1 pair (2 ampoules ) of Pabrinex IV q8h
- (28% of attendances, 12 % of whom need admission)
- It contributes up to 40% of all acute medical admissions
- Accounts for 12% of the total NHS spend
Alcohol withdrawal
Symptoms are variable in intensity. Severe alcohol withdrawal symptoms can occur in patients admitted to hospital either for the prime purpose of alcohol withdrawal (primary detoxification) or for other medical/surgical reasons resulting in their alcohol being withdrawn (secondary detoxification). Secondary detoxification accounts for 90% of all alcohol withdrawals in hospital.
Heavy alcohol consumption and alcohol withdrawal are associated with a range of neuropsychiatric conditions. Vitamin B deficiency is known to contribute to the aetiology of a number of these conditions. In addition to sedation regimes, vitamin B supplements are central to the management of alcohol withdrawal.
If there is a suspicion of encephalopathy, the patient must receive high dose intravenous Pabrinex.
Alcoholic patients without suspicion of encephalopathy should be treated with oral Thiamine [BestBets].
Severe withdrawal - predicted if patients have had:
- High levels of alcohol intake
- Past Hx of severe withdrawal
- Past Hx of seizures or delirium
- Concomitant use of psychoactive drugs
- Poor physical health
- High levels of anxiety
- Other psychiatric disorders
Severe alcohol withdrawal states include:
- Delirium tremens,
- Alcohol withdrawal seizures
- Alcoholic hallucinations
- Blackouts
Wernicke's encephalopathy
Vitamin B deficiencies frequently associated with alcohol misuse. Deficiency can result in Wernicke's encephalopathy (WE) a reversible biochemical lesion of the CNS caused by overwhelming metabolic demands being made upon depleted B vitamins reserves (also known as Wernicke-Korsakoff Syndrome - WKS). As well as being associated with chronic morbidity in the form of Korsakoff's psychosis, WE can have major long-term consequences, resulting in long term brain damage and institutional care.
However, only 10% of patients have the full triad. The majority (82%) present with an altered consciousness level (confusion).
- WE occurs in 12.5% of alcohol misusers
- WE is fatal in up to 20% of inappropriately managed patients
- 85% of survivors suffer permanent brain damage
- 25% require permanent institutional care
- Only 5 -18% diagnosed in life
- WE is reversible with early diagnosis and prompt treatment
| Clinical Hx | Wt ↓ in past year ↓BMI Poor nutritional status High carbohydrate intake Recurrent vomiting Anaemia, pellagra - diet etc |
|---|---|
| Early signs | Anorexia N/V Fatigue, apathy Giddy, diplopia Insomnia, anxiety Memory loss |
| Late signs | Classic triad of
Eye abnormalities |
Who to treat - incipient WE
All patients with any evidence of alcohol misuse with any of the following
- Acute confusion
- Decreased conscious level
- Memory disturbance
- Ataxia
- Ophthalmoplegia
- Hypothermia / hypotension
At risk
Particularly at risk are those with coexisting factors placing additional demands on the vitamin B stores :
- Intercurrent illness
- DTs
- Alcohol seizures
- Other alcohol related admissions
All hypoglycaemic patients (who are treated with IV glucose) with evidence of chronic alcohol ingestion must have IV Pabrinex immediately because of the risk of precipitating WE.
How to treat
Treatment is 1 pair of Pabrinex (repeated q8h on the ward for up to 8 days)
Pabrinex should be diluted in 100ml saline or dextrose (infused over 30 mins).
Risk of Anaphylaxis
Parenteral high potency vitamin B has been associated with a very small risk of serious allergic adverse reactions. Patients with incipient WE require admission where intravenous B vitamins can be administered and continued in a safe environment.