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This guide is for assessing a patient in whom you are concerned about the side effects of alcohol misuse disorder (Alcoholism / ETOH abuse is the less politically correct term). You need to identify who needs an alcohol withdrawal scale (+/- diazepam loading) early. Then, you need to admit those with Delirium Tremens or Wernicke's/Korsakoffs. Most patients with withdrawal do not require a medical admission. Simple withdrawals can usually be managed in short stay, but DTs require medical admissions, while korsakoffs dementia (permanenent brain failure!) patients will require admissions for discharge planning.

Step 1: Assess for signs of alcohol withdrawal

Signs of Autonomic Excitation: tremor, anxiety, sweating, tachycardia, hypertension, nausea, hyperthermia.
Signs of Neuro Excitation: hyperreflexia, hallucinations, seizures.

[CopyPasta -ve] The patient’s vital signs are WNL (afebrile, normotensive, not tachycardic) and there are no signs of autonomic excitation (tremor, anxiety, sweating, nausea.). There are also no signs of significant neuroexcitation – patient has normal reflexes, and there is no history of seizures or evident hallucinations during the interview.

Step 2: Assess for Delirium Tremens

Usually occurs 3 days after the last drink. worse at night.

Look for:
1) Withdrawal symptom – use Alcohol Withdrawal Scale of your choosing.
2) Confusion / Delirium – acute inattention. Serial subtraction Dec-Jan / 20 to 0 / 100 to 0 subtracting 7/ CASABLANCA / 4AT.
3) Perceptual disturbance – overt hallucinations or delusions.
4) CVS instability – abnormal vital signs

Step 3: Screen for Wernicke’s Encephalopathy and Korsakoff’s Dementia

Wernicke’s Encephalopathy
An acute life threatening confusion, incoherence and attention deficit.
Two thirds of wernicke’s progress to korsakoff’s. some get better. 1 in 5 die.
Acute confusion, progressing to decreased GCS.

Memory disturbance
Ataxia
Opthalmoplegia.
Nystagmus.
Hypotension
Hypothermia

[CopyPasta -ve] Excluding Sx Wernicke’s Encephalopathy
I do not suspect wernicke’s encephalopathy as pt demonstrates:
– Intact short term memory (three word recall) and intact long term memory (address / phone number)
– No signs of inattention. Can state months Dec to Jan easily.
– Normal conjugate gaze
– No evidence of ataxia – observed normal gait, able to walk heel to toe. Finger-nose and Heel-shin tests are unremarkable.
– No pathological horizontal/vertical/rotational nystagmus.

[CopyPasta -ve] Excluding Sx Korsakoff’s syndrome
I do not suspect Korsakoff’s Dementia as pt demonstrates
– no evidence of confabulation during the interview.
– reasonable ability to follow three stage command, and is able to recall commands afterwards.
– Short term recall of three words normal (eg. “ball, pen, man”) over 10 minutes is intact.