Wernicke’s encephalopathy
Wernicke’s encephalopathy (WE) is an acute neuropsychiatric emergency caused by severe thiamine (vitamin B1) deficiency. It is most commonly seen in people with chronic alcohol use disorder but can occur with any cause of malnutrition or increased metabolic demand.
In the emergency department the priority is clinical recognition and immediate parenteral thiamine - do not delay treatment for investigations. (NICE CG100)
Why it matters in the ED
- WE can present variably as unexplained acute confusion, falls, new ataxia or ocular disturbance in at‑risk patients (for example, heavy alcohol use, malnutrition, recent poor oral intake).
- Administration of glucose without thiamine may precipitate or worsen WE.
- Untreated WE can progress to irreversible Korsakoff syndrome (profound anterograde amnesia and confabulation) or death.
- NICE recommends urgent parenteral thiamine for suspected WE and continuing parenteral therapy for a minimum of 5 days unless WE is confidently excluded (NICE CG100).
Clinical features
WE is classically described as a triad, but the complete triad is often absent. A low threshold for treatment is required when risk factors and any compatible sign are present.
Typical features
- Acute confusion or altered mental state.
- Oculomotor abnormalities: nystagmus, gaze palsies, ophthalmoplegia, diplopia.
- Gait ataxia or incoordination.
Other possible features