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Prevention and Treatment of Wernicke-Korsakoff Syndrome (WKS) in Accident & Emergency Departments (A&E)

1. The Problem
2. The Aim
3. Treatment
4. Who to Treat
5. Follow-up
6. References

1. The Problem

WKS is a potentially lethal condition, due to thiamine deficiency. WKS can also have major long term consequences, with patients requiring permanent institutional care. It is commonest in heavy drinkers who have a poor diet. Such patients may be unpopular with staff if unkempt, drunk or abusive.

Most alcohol dependent patients presenting to A&E will spontaneously leave on sobering up. The common signs of WKS - confusion, ataxia and coma - are difficult or impossible to differentiate from drunkenness. The eye signs (ophthalmoplegia/nystagmus) are present in only 29% of cases. Because of this, WKS may go unrecognised unless considered.

Heavy drinkers presenting to A&E - often collapsed and/or with a head injury - require repeated neurological assessment.

The intoxicated patient who does not recover fully and spontaneously may be suffering from WKS. Only if such a patient is admitted will full assessment be possible and further treatment be practical.

There is no simple blood test to determine patients at risk of WKS.

2. The Aim

To prevent the development of, and to treat symptoms of, WKS by administration of parenteral B complex vitamins.

3. Treatment

The only available intravenous (i.v.) treatment which includes thiamine (B1), riboflavin (B2), pyridoxine (B6), and nicotinamide is Pabrinex (Parentrovite was discontinued 1993). The intramuscular Pabrinex preparation includes benzyl alcohol as a local anaesthetic.

Two pairs of vials of Pabrinex 1 and 2 diluted in 100ml of crystalloid should be given i.v. over 30 minutes initially (anaphylaxis is rare). 1 pair of vials t.d.s. for 5 days to follow at the discretion of the admitting team (mandatory for any patient with evidence of WKS when sober). Oral treatment of WKS is ineffective even if such patients comply.

4. Who to Treat

All patients with any evidence of chronic alcohol misuse and any of the following: acute confusion, ataxia, ophthalmoplegia, memory disturbance, hypothermia, hypotension, when initially seen in A&E (may well be drunk).

All hypoglycaemic patients (who are treated with i.v. glucose) with evidence of chronic alcohol ingestion must be given i.v. thiamine immediately because of the risk of acutely precipitating WKS.

5. Follow-up

All such patients should be offered support for reducing dependence on alcohol, e.g. referral to an Alcohol Health Worker.

If the patient is admitted, e.g. to detoxify or for delirium tremens, it may then be possible to distinguish signs of WKS from those of drunkenness

6. References:

Cook CCH, Thomson AD (1997): B-complex vitamins in the prophylaxis and treatment of Wernicke-Korsakoff syndrome. Br. J. Hosp. Med. 57, 461-465.

Touquet R, Fothergill J, Henry JA, Harris NH (2000): Accident and emergency medicine. Chap. 29. In: Clinical negligence. 3rd ed., Eds: Powers,MJ; Harris,NH, Butterworths, London, p989-1037. (see para 29.103).

Mr R Touquet
Consultant in Accident & Emergency Medicine

Professor J Henry
Accident & Emergency Medicine

Professor C Cook
Psychiatry of Alcohol Misuse

Dr A Thomson
Consultant Physician

last modified: 14th August 2000