Alcohol

ALCOHOL

Wernicke’s Encephalopathy

COMMON CAUSE
50 – 75% of W.E.

• Alcohol
  • dietary intake
  • GI absorption
  • hepatic storage
  • impaired use

OTHER CAUSES

• Malabsorption
• Poor Intake
• anorexia
• hyperemesis pregn
• IV feeding
• fasting
• GI surg
• bariatric surg
• Metabolic Req
• systemic illness
• transplant
• AID
• Loss of vitamins
• renal dialysis

CLINICAL TRIAD:

Only seen in 1⁄4 pts
W.E. is often under diagnosed

1. ENCEPHALOPATHY (82%)

   • Disorientation, Indifference, Inattentiveness. 5% have ↓ed LOC

2. OCCULOMOTOR DYSFUNCTION (29%)

   • Nystagmus, Lateral Rectus Palsy, Conjugate Gaze Palsy, INO, Unequal Pupils, Light near dissociation, Nonreactive pupils, etc

3. GAIT ATAXIA (23%)

   • Primarily: Stance & gait
   • Unlike Alcoholic Cerebellar Degeneration
   • W.E. has no upper limb ataxia

OTHER:

• peripheral neuropathy,
• hypothermia, cardiac, vestibular

Vitamin B1 (Thiamine) Deficiency

TREATMENT: If suspected

• Thiamine & Thiamine
• Thiamine BEFORE Glucose
• Check Magnesium

KORSAKOFF’S SYNDROME

• Chronic disease, progressed from untreated W.E.
• Severe retrograde & anterograde amnesia
  • with relatively preserved long term memory, cognitive, and social skills
• Confabulation sometimes present.
• Pt unaware of their illness

Alcohol Withdrawal

• 70 % of AD patients &↑ Rate in the elderly.

• No gender/ethnic differences

• 85% mild-to-moderate

• 15% severe and complicated:

  • Seizures
  • Delirium Tremens

• Features:

  • Tremulousness (hands, legs and trunk).
  • Nausea, retching and vomiting.
  • Sweating, tachycardia and fever.
  • Anxiety, insomnia and irritability.
  • Cognitive dysfunctions.
  • Thinking and perceptual disturbances.

Course of AW

Stages

• I (24 – 48 hours):

• II (48 – 72 hours):

• III (72 – 105 hours):

• IV (> 7 days):

Symptoms

• ➢ Peak severity at 36 hours
• 90% of AW seizures
• Most cases self-limited
• ➢ ↑ Stage I symptoms
• ➢ “Delirium Tremens”
• ➢ Protracted withdrawal

Delirium Tremens

Features:

• delirium.
• gross tremor.
• autonomic disturbances.
• dehydration and electrolyte disturbances.
• marked insomnia.

Course:

• peaks on third or fourth day, lasts for 3 – 5 days, worsens at night, and followed by a period of prolonged deep sleep.

Complications:

• seizures.
• chest infection, aspiration.
• violent behaviour.
• coma.
• death; mortality rate: 5-15%. Why?

Treatment of Delirium Tremens

• The best treatment is prevention
• Supportive
• Thiamine
• The mainstay treatments are benzodiazepines.
• Avoid antipsychotics.

Treatment of Alcohol Withdrawal & Delirium Tremens (1st Approach)

Table 21.1 Symptom-triggered therapy using CIWA-Ar

• Medication q 1 hour for a score ≥ 10
• Chlordiazepoxide 50–100 mg
• Diazepam 10–20 mg
• Lorazepam 2–4 mg
• Determine total 24-hour dose
• Taper 20% per day

Key
CIWA-Ar = Clinical Institute Withdrawal Assessment for Alcohol, Revised

Treatment of Alcohol Withdrawal & Delirium Tremens (2nd Approach)

Table 21.2 Fixed schedule regimens for alcohol withdrawal

• Chlordiazepoxide 50 mg q 6 hours for 4 doses, then 25 mg q 6 hours for 8 doses
• Diazepam 10 mg q 6 hours for 4 doses, then 5 mg q 6 hours for 8 doses
• Lorazepam 2 mg q 6 hours for 4 doses, then 1 mg q 6 hours for 8 doses
• Monitor vital signs and other symptoms and give additional medication prn.
• Continue tapering over the next one to two days.