Alcohol: withdrawal + thiamine deficiency Flashcards
What is a common cause of alcohol withdrawal?
Iatrogenic - patient stuck in hospital
When does simple alcohol withdrawal present?
6-12 hours after last drink
How does simple alcohol withdrawal present?
1) Insomnia
2) Tremor
3) Anxiety
4) Agitation
5) N&V
6) Sweating
7) Palpitations
When does alcohol hallucinosis present?
12-24 hours post drink
How does alcohol hallucinosis present?
Hallucinations of visual, tactile or auditory origin
When does delirium tremens present?
48-72 hours post-drink
How does delirium tremens present?
1) Delusions + visual hallucinations
2) Confusion
3) Seizures
4) Tachycardia
5) Hypertension
6) Hyperthermia
What are indications for inpatient withdrawal?
1) Patients drinking >30 units per day
2) Scoring > 30 on the SADQ score
3) High risk of alcohol withdrawal seizures (previous alcohol withdrawal seizures or delirium tremens, or history of epilepsy)
4) Concurrent withdrawal from benzodiazepines
5) Significant medical or psychiatric comorbidity
6) Vulnerable patients
7) Patients under 18
When is assisted alcohol withdrawal required?
1) Drinking > 15 units per day
2) Scoring > 20 on the AUDIT
How is assisted alcohol withdrawal carried out?
1) Chlordiazepoxide is prescribed in a reducing regimen in accordance with the CIWA score + local protocol
2) Pabrinex (1 pair of ampoules daily to prevent WE)
What is the first line treatment of an alcohol-withdrawal seizure?
IV lorazepam (rapid-acting benzodiazepine)
What should patients on assisted alcohol withdrawal be prescribed if there are any signs of WE (confusion, ataxia, ophthalmoplegia or nystagmus)?
2 pairs of Pabrinex ampoules TDS
What is first-line treatment for delirium tremens?
Oral lorazepam
What is second-line treatment for delirium tremens if oral lorazepam is declines or symptoms persist?
Parenteral lorazepam
What causes Wernicke’s encephalopathy (WE)?
Thiamine (B1) deficiency
What causes WE?
1) Chronic alcohol abuse
2) Malnutrition
3) Bariatric surgery
4) Hyperemesis gravidarum
How does WE present?
Triad of ataxia + confusion + ocular abnormalities
What ocular abnormalities can occur in WE?
1) Gaze-evoked nystagmus
2) Spontaneous upbeat nystagmus
3) Horizontal or vertical ophthalmoplegia
How is WE treated?
IV Pabrinex (high dose IV thiamine)
What can WE progress to if left untreated?
Korsakoff’s syndrome
What is Korsakoff’s syndrome?
This affects the mammillary bodies to cause irreversible deficits in anterograde and retrograde memory
How does Korsakoff’s syndrome present?
1) Profound anterograde amnesia with limited retrograde amnesia
2) Confabulation - patients fabricate memories to mask the memory deficit
What is the pathophysiology of Korsakoff’s syndrome?
1) Korsakoff’s syndrome is thought to be a result of degeneration of the mammillary bodies
2) The mammillary bodies are part of the circuit of Papez which plays a role in memory formation
What other medications can be used in to help treat alcohol withdrawal?
Oral acamprosate or naltrexone
