Always give Pabrinex to anyone who is malnourished or alcoholic or hyperemesis. It contains ascorbic acid 500 mg, anhydrous glucose 1 g, nicotinamide 160 mg, pyridoxine hydrochloride 50 mg, riboflavin 4 mg, and thiamine hydrochloride 250 mg in a total of 10 ml especially before giving carbohydrates /glucose. If untreated Wernicke-Korsakoff syndrome may lead to an irreversible amnestic state.
|Initial Management Summary|
- Assess need for treatment of Delirium Tremens
- Commence Pabrinex 2-3 pairs of ampoules IV over 10 min every 8 h
- Do not give IV glucose until Thiamine has been given
- Described in 1881 by Carl Wernicke
- Damage to memory - confusion, ataxia, and nystagmus
- Usually due to Thiamine deficiency
- The body stores 18 days worth of Thiamine
Clinical Signs of Acute Wernicke's encephalopathy
- Ophthalmoplegia (diplopia) horizontal and vertical nystagmus,
- Weakness of lateral rectus, weakness of conjugate gaze
- Ataxia : unsteadiness of standing and walking
- Confusion: Confabulation and inattention and confusion
- May have a polyneuropathy or cerebellar signs
If untreated, this condition could develop into a Chronic Korsakoff’s Syndrome, which presents symptoms such as:
- Severe if not permanent memory loss.
- Confabulation – Making up stories of oneself.
- Hallucinations – Seeing things that are not present.
- Inability to form new memories.
- Precipitants include infection, surgery, trauma, or a carbohydrate load
- Alcoholism: Alcohol prevents uptake of thiamine leads to a decrease of thiamine pyrophosphate from thiamine as well as the liver’s capacity to store thiamine itself.
- Anorexia nervosa
- Hyperemesis gravidarum in pregnancy
- Weight loss / Bariatric surgery
- Any persisting sickness and nausea, starvation etc
- Hepatic encephalopathy: Ammonia levels
- Encephalitis - consider LP/MRI
- Alcohol induced peripheral neuropathy or cranial neuropathies
- Tumours or lesions involving the hypothalamus
- Syphilis, Carbon monoxide poisoning, Head Injury and SAH
Mamillary body, medial thalamus hypothalamus, Periaqueductal grey matter involved. T2 and FLAIR hyper and restriction of diffusion
- Check U&E, Mg, LFTs and general confusion screen
- Reduced red cell transketolase and ? thiamine levels and ? pyruvate levels
- CT brain: exclude bleed or SDH
- Brain MRI might show specific atrophy in diencephalic structures in Korsakoff's syndrome. T2 weighted changes in the thalamus (memory loss) and periaqueductal grey matter (causing eye signs)
- ABG: exclude hypoxemia, hypercarbia, acidosis, or alkalosis, COHb
- Post mortem: punctate haemorrhages affecting the gray matter around the third and fourth ventricles and aqueduct of Sylvius
- Thiamine replacement e.g. Pabrinex contains parenteral vitamin B and C should be used for the first 3 days or IV/IM Thiamine 100 mg for 3-7 day and then orally long term before giving any carbohydrates. Others have suggested larger doses of 500 mg IV TDS for 2-3 days. Anaphylactic reactions to parenteral thiamine do occur.
- Correct any deficiency of electrolytes, particularly magnesium and potassium and review any sedation.
- Manage ongoing alcohol abuse and abstention - community alcohol abuse treatment
- May need psychiatric management for long term cognitive and behavioural issues