Wernicke Encephalopathy — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Suspected Wernicke?
   High-risk + neurological signs — suspected Wernicke (Caine criteria)? (Thiamine (B1) deficiency causing an acute neurological emergency. The triad (altered consciousness + ophthalmoplegia/nystagmus + ataxia) is complete in only ~16% (do not wait), altered consciousness is most common; untreated → Korsakoff (permanent memory impairment). High-risk: alcohol use + malnutrition, post-bariatric surgery, hyperemesis gravidarum, dialysis, malignancy, prolonged vomiting. Caine criteria (≥2/4, 85% sensitive): dietary deficiency, oculomotor abnormality, cerebellar dysfunction, altered consciousness/memory.)
   • Suspected Wernicke (high-risk / Caine ≥2) → Suspected Wernicke → IV thiamine
   • Does not fit → Does not fit
2. [End] Does not fit
   Evaluate other causes of altered consciousness/eye movements/ataxia (stroke, intoxication, metabolic encephalopathy, infection, etc.) along the appropriate pathway; in any high-risk patient with altered consciousness, still give thiamine before glucose.
3. [End] Suspected Wernicke → IV thiamine
   IV high-dose thiamine (e.g. 500 mg IV tid × 2–3 days then taper), before or together with any glucose-containing fluid (giving glucose first can precipitate/worsen WE). Correct hypomagnesemia (a thiamine cofactor; thiamine is ineffective when magnesium is low); clinical diagnosis (Caine criteria), MRI (mammillary bodies/periaqueductal/medial thalamus) supports it but do not delay for imaging; after treatment eye signs improve over days, ataxia/consciousness over weeks; watch for refeeding syndrome.

Source guidelines & references

• Wernicke encephalopathy (Caine criteria; EFNS guideline; StatPearls)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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