Q for all of You.
If i were to tell you that there is a disease entity that has-
an estimated prevalence of 2% in the US
significant morbidity
is easily treatable
and that many of us have likely missed it in the ED
Would you know what it is?
Well. You're about to.
Wernicke Encepahalopathy.
What is it?
An encephalopathy that occurs secondary to thiamine (B1) deficiency
It's a disease only seen in alcoholics, right?
ehhh, not quite.
Wernicke most commonly is found in alcoholics (an estimated 12.5% of them), but has also been found in people who have bariatric surgery, hyperemesis gravidarum, and AIDS (one study found evidence of wernicke in 10% of autopsies in AIDS patients)
Well how does it present.
Classically has a triad of ataxia ophthalmoplegia, and AMS
though the full triad is only seen in <10% of patients
Is there a diagnostic tool available?
Sure is, diagnosis is made with 2/4 of the following criteria
Dietary deficiencies
Oculomotor deficiencies
Cerebellar Dysfunction (ataxia)
AMS/mild memory impairment
Why is it important that I treat it?
An estimated 60% of patients will have residual defecits
How do I treat it
pretty simple.
THIAMINE.
500mg IV thiamine three times a day for 3 days, followed by 250mg IV for 2-3 days
there is conflicting evidence about the amount of thiamine to give. Yet all agree that thiamine is relatively harmless- basically just give a lot of thiamine
IV administration is important here. chronically malnourished patients (especially those with ethanol usage) do not absorb thiamine well in the GI tract.
co-administer magnesium IV - hypomagnesemia promotes thiamine resistance
the 100mg we give in our bannana bags is preventative, and can provide sufficient thiamine for 1 week
So you're saying every confused alcoholic that's stumbling in the ED requires hospital admission for IV thiamine? That'll do great for our boarding issues in the ED
Not quite.
But if your drink patient is clinically sober and is then witnessed to have a wide based gait on their way out the ED. take a minute. have a conversation. do a brief ocular neuro exam. look for weird eyeball movements.
often times patients will have rapid improvement from an IV thiamine dose (within 30 minutes). While not specific, if this happens the patient should definitely be admitted for IV thiamine.
How about that thiamine before glucose thing. Do i need to withhold glucose from a hypoglycemic alcoholic.
Meh. NO!
in theory, a glucose load increases thiamine requirements. The though was that giving a dextrose load can push the at risk patient into Wernicke. But studies have not shown this to be the case.
give your hypoglycemic patient glucose. just do it. Swoosh style.
What's the pathophysiology behind it?
Never thought you'd ask!
Every ED docs favorite cycle - the Krebs cycle
Thiamine is a co-factor for pyruvate dehydrogenase, which converts pyruvate --> Acetyl-CoA, which then enters the Krebs cycle and results in ATP production
So no thiamine = no ATP
no ATP = bad.
That's all.
-Elly