Alcohol Withdrawal and Wernicke's Encephalopathy (1)

Question 1

What are the stages of symptoms? What time would you expect each?

What are the 2 main medications given to manage this?
→ Why are these given?
→ What is given if the pt enters DT?

Answer 1

➊ • 6-12 hrs – Tremor, Sweating, Headache, Craving, Anxiety
• 12-24 hrs – Hallucinations
• 24-72 hrs – Delirium Tremens (Confusion, Seizures, Tachycardia, HTN)

N.B. Commonly tactile hallucinations, where they feel spiders crawling on their skin

➋ • Chlordiazepoxide – Benzo given as a reducing regime, titrated to the required dose based on hospital protocol
• Pabrinex (High-dose B vitamins) – Followed by regular, low-dose oral Thiamine
→ To prevent Wernicke-Korsakoff Syndrome (WKS)
→ Lorazepam

Question 2

Delirium Tremens:
When do symptoms usually peak?

What’s the effect of alcohol on the brain?

What’s the resulting effect of chronic alcohol use on the brain?
→ What occurs with withdrawal?

Answer 2

➊ Day 4-5

➋ • Stimulates GABA receptors in the brain, which have a relaxing effect on the rest of the brain
• Inhibits Glutamate/NMDA receptors, therefore having an inhibitory effect on brain electrical activity

➌ Downregulation of GABA system, and Upregulation of Glutamate/NMDA system to balance the long-term effects of alcohol
→ These dysfunctions cause extreme brain excitability

Question 3

What are the features of DT?

How is it managed?

Answer 3

➊ • Confusion
• Hallucinations
‣ Particularly visual and tactile hallucinations (such as formication – feeling crawling insects on/under skin)
• Agitation
• Sweating
• Tremor
• Tachycardia
• HTN

➋ • Lorazepam
• Maintenance management of alcohol withdrawal i.e. Chlordiazepoxide, Pabrinex

Question 4

Wernicke’s Encephalopathy:
What is it due to?

Why’s it more common in alcoholics?

How does it present?

How is it treated?
→ What does this prevent?
→ What needs to be checked before giving this?

Answer 4

➊ Thiamine (Vit B1) deficiency

N.B. It’s associated with lesions in the mammillary bodies

➋ Thiamine is poorly absorbed in the presence of alcohol, and alcoholics tend to have poor dietary intake

➌ Triad of Confusion, Ataxia, Ophthalmoplegia (nystagmus, lateral rectus and conjugate gaze palsies)

➍ Urgent IV Pabrinex
→ Korsakoff’s syndrome
→ Glucose – Thiamine should be given before glucose in hypoglycaemics, which most of these pts are, as Wernicke’s can be precipitated by giving glucose first

N.B. Glucose metabolism requires Thiamine

Question 5

Korsakoff’s Syndrome:
What occurs here?

What are its features?

Answer 5

➊ Hypothalamic damage and Cerebral atrophy due to Thiamine deficiency

➋ • Memory impairment
‣ Anterograde – Reduced ability to make new memories
‣ Retrograde – Pts confabulate (fabricate memories to mask the memory deficit)
• Behavioural changes – Lack of insight, Apathy

N.B. Often irreversible and results in pts being in full-time institutional care