What is the workup for a patient with syncope and amnesia, and a history of alcohol (ethanol) use disorder?

From the Guidelines

The workup for a patient with syncope, amnesia, and a history of alcohol use disorder should begin with a thorough history and physical examination, focusing on cardiac, neurological, and metabolic causes, and initial testing should include orthostatic vital signs, electrocardiogram (ECG), complete blood count, comprehensive metabolic panel, blood glucose, and toxicology screening including blood alcohol level, as recommended by recent guidelines 1.

When evaluating a patient with a history of alcohol use disorder, it is essential to consider the potential for alcohol withdrawal syndrome (AWS) and Wernicke's encephalopathy, as highlighted in the Kasl clinical practice guidelines 1. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale can be helpful in assessing the severity of AWS, but high scores may be seen in psychiatric conditions that are similar to AWS, such as anxiolytic withdrawal, anxiety disorder, and physical conditions such as sepsis, hepatic encephalopathy, and severe pain.

Key points to consider in the workup include:

• Quantification of alcohol use: in grams per week, using standardized surveys and electronic health records to improve accuracy 1
• Assessment of drinking patterns: daily intake and binge drinking, as well as potential socio-economic consequences of alcohol use 1
• Evaluation of metabolic dysfunction: including the diagnosis of cardiometabolic risk factors, such as high blood pressure, hypertriglyceridaemia, and hyperglycaemia, and the potential impact of alcohol use on these factors 1
• Neurological assessment: including electroencephalogram (EEG) and brain imaging (CT or MRI) to rule out seizures, structural abnormalities, or Wernicke-Korsakoff syndrome 1

The initial management should include thiamine 100mg IV administered before glucose to prevent precipitating Wernicke's encephalopathy, and benzodiazepines, such as lorazepam 1-2mg IV/PO every 4-6 hours as needed, or diazepam 5-10mg IV/PO every 4-6 hours as needed, with dosing adjusted based on symptoms, as recommended by the Kasl clinical practice guidelines 1.

Additional testing and management may include:

• Echocardiogram and possibly Holter monitoring or tilt-table testing if cardiac syncope is suspected
• Nutritional supplementation, including thiamine 100mg IV/PO daily for at least 3-5 days, folate 1mg daily, and multivitamins
• Assessment for alcohol withdrawal using the CIWA scale and treatment with benzodiazepines as needed
• Consideration of the potential for metabolic dysfunction and alcohol-related liver disease, and the need for integrated approaches to manage these conditions, as highlighted in the position statement by an expert panel on alcohol-related liver disease 1

From the Research

Workup for Patient with Syncope and Amnesia

The workup for a patient with syncope and amnesia, and a history of alcohol (ethanol) use disorder, involves several key components:

• Thiamine supplementation: Patients with alcohol use disorder frequently have a thiamine deficiency, which can lead to Wernicke's encephalopathy, a potentially life-threatening complication 2, 3.
• Assessment for Wernicke's encephalopathy: Early supplementation of thiamine is crucial to avoid irreversible neurological damage, and patients at high risk should immediately receive an intravenous or intramuscular dose of thiamine 2, 3.
• Evaluation for alcohol withdrawal syndrome: The alcohol withdrawal syndrome (AWS) is a common management problem in hospital practice, and patients with AWS may have mild symptoms or more severe symptoms that require close inpatient supervision and benzodiazepine therapy 4.
• Neurological examination: A thorough neurological examination is necessary to assess for signs of Wernicke's encephalopathy, such as confusion, dysarthria, nystagmus, and supranuclear ophthalmoplegia 5.
• Imaging studies: Magnetic resonance imaging (MRI) with gadolinium enhancement may show brain lesions consistent with Wernicke's encephalopathy, and symmetric hyperintensities on T2-weighted images in the globus pallidus may be seen in cases of disulfiram intoxication 5.
• Laboratory tests: Biochemical serum and cerebrospinal fluid analyses, as well as electromyogram, may be normal or detect motor polyneuropathy 5.
• Cognitive assessment: Cognitive assessment may reveal severe impairment of memory, attention, and logical and executive abilities 5.

Treatment

Treatment for a patient with syncope and amnesia, and a history of alcohol (ethanol) use disorder, may involve:

• Thiamine supplements: High-dose thiamine supplements, such as parenteral thiamine 200-500mg three times a day, followed by oral thiamine 250-1000mg/day 3.
• Benzodiazepines: Benzodiazepine therapy, such as chlordiazepoxide, may be necessary to manage alcohol withdrawal syndrome 6, 4.
• Hydration: Hydration is essential to prevent dehydration and electrolyte disturbances 5.
• Disulfiram cessation: Stopping disulfiram and treating with thiamine supplements and benzodiazepines may improve the patient's consciousness and oculomotor function 5.
• Neurorehabilitation: Intensive neurorehabilitation may be necessary to improve cognitive function and overall recovery 5.