This is a new type of post for First10EM. I frequently come across excellent papers that contain just a little too much information for the Articles of the Month reviews, but don’t really fit with the first 10 minutes resuscitation theme of the website. Up until now, I have simply not been sharing the information in these papers, but that seems like a bit of a waste. This is this trial of a new type of post – the rapid reviews – where I will briefly review the key points from a paper I read. Let me know what you think. If it needs to die, this can be the last post. If you like these, I will keep them coming.
Our topic: Wernicke-Korsakoff Syndrome (WKS)
The paper: Sharp CS, Wilson MP, Nordstrom K. Psychiatric Emergencies for Clinicians: Emergency Department Management of Wernicke-Korsakoff Syndrome. The Journal of emergency medicine. 51(4):401-404. 2016. PMID: 27553920
What is it?
A (primarily) neurologic disorder resulting from thiamine (vitamin b1) deficiency.
What are the symptoms?
The classic triad is mental status changes, ophthalmoplegia, and gait ataxia. However, only 20% of patients will have all three. According to the Caine criteria, you should make the diagnosis if a patient has 2 or more of:
- Dietary deficiencies
- Oculomotor abnormalities
- Cerebellar dysfunction
- An altered mental status or mild memory impairment
Who gets it?
The condition is probably underdiagnosed, as autopsy studies estimate the prevalence of WKS as 0.4-2.8%. In general, we think of this condition in chronic alcoholics with poor diets. However, there are many other conditions that predispose to WKS. For example, approximately 10% of AIDS patients have signs of WKS at autopsy. You should also consider the diagnosis in patients with hypermetabolic states (eg, hematologic malignancies) and hemodialysis patients.
How should we treat it?
You give thiamine. More than that, there is no evidence based answer. The traditional dose is 100mg PO daily. Some will give 500 mg IV TID for the first 3 days. Others 200 mg IV TID. Others give as much as 1500 mg daily. Really, just making the diagnosis and giving the thiamine is probably all that matters.
Weird Trivia: Although we normally think of WKS as being associated with chronic alcoholism, the first case ever described was actually in a 20 year old non-alcoholic woman. She developed pyloric stenosis after a failed suicide attempt by ingesting sulphuric acid and ultimately developed WKS due to severe malnutrition.