Amazing, Amusing & Awesome Acidosis Anecdotes And Gnarly Mnemonics Kent R. Olson, md



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Amazing, Amusing & Awesome Acidosis Anecdotes . . . And Gnarly Mnemonics

  • Kent R. Olson, MD

  • Medical Director

  • California Poison Control System

  • Clinical Professor of Medicine

  • UC San Francisco


Case 1: An Acidic Alcoholic

  • A 44 yo man was found unconscious, with a suicide note and a half-empty bottle of Jim Beam.

  • BP 110/80 HR 110 RR 24

  • pH 7.47 pCO2 22 pO2 88

  • Na 140 K 3.8 Cl 106 HCO3 18

  • ETOH 0.18 gm/dL



Causes of Metabolic Acidosis:

  • “MUDPILES”

  • Methanol

  • Uremia

  • DKA

  • Phenformin, Paraldehyde

  • INH, Iron

  • Lactic acid

  • Ethylene glycol

  • Salicylate



Salicylate Intoxication:

  • Typical mixed acid-base abnormality:

  • May be acute or chronic

  • Large OD may cause delayed peak

  • Treatment:

    • Alkalinize urine, restore serum pH
    • Hemodialysis


Case 2: A Gapped Gipper

  • 30 yo M found comatose

  • Temp 86F, pH 6.9

  • Na 147, K 4.9, Cl 105, Bicarb 5

    • Anion gap 37
  • Glu 166, BUN 16, Cr 1.5

  • Measured Osm 331

    • Osm gap 23
  • Ethanol “zero”



The Osmolar Gap:

  • Osm = 2 (Na) + BUN/2.8 + Glucose/18

  • Gap = Measured - Calculated Osm = 0 + 5

  • Causes of Osm Gap:

    • Ethanol
    • Isopropyl alcohol & Acetone
    • Methanol & Ethylene glycol
    • Other alcohols & glycols
  • Erroneous results:

    • Wrong tube; Different specimen times
    • Falsely normal gap with vaporization method




Ethylene Glycol & Methanol:

  • Osmolar gap

  • Anion gap

    • Lactate low, does not account for gap
    • Early in the intoxication, anion gap may be absent
  • Additional clues: (may be unreliable)

    • EG: urine crystals, fluorescence
    • Methanol: visual disturbance


Ethylene Glycol & Methanol:

  • Main DDx: Alcoholic Ketoacidosis

    • Anion and Osmolar gaps
    • Low lactate
    • AKA clues:
      • GETS BETTER over a few hrs with fluids and dextrose
      • Ketone levels +/- (beta-hydroxybutyrate)


Case 3: Not on the List

  • A 15 year old young woman was found comatose (GCS 7)

  • BP 92/34 mm Hg HR 120/min

  • RR 24/min pulse ox 94% (room air)

  • pH 7.16 pCO2 27 pO2 127

  • Anion gap 20

    • Salicylate negative
    • Methanol, EG negative


Case 3, cont.

  • She became more obtunded and was intubated

  • Treated with IV fluids

  • Received bicarbonate 50 mEq x 1

  • Recovered, extubated in 12 hours

  • Admitted to ingesting 500 ibuprofen tablets (200 mg size)



Ibuprofen

  • Common NSAID

  • Propionic acid derivative

    • Contributes to acidosis
    • (Naproxen is also a PA derivative)
  • Moderate OD: GI upset

  • Severe OD:



Case 4: A Surprising Finding

  • 28 yo F found comatose in a hotel room, 2 empty bottles of Extra Strength Tylenol (total about 150 gm)

  • BP 120/50, HR 130, pupils midrange

  • pH 7.03, HCO3 4, anion gap 25

  • ASA negative, APAP 850 mg/L

  • AST 70

  • Lactate >11 mmol/L



Acetaminophen

  • Case (continued):

    • ETOH, Methanol, Ethylene Glycol tests all negative
    • Patient later developed liver, renal failure


Acetaminophen

  • Massive ingestion:

  • Different mechanism than hepatic injury



Cases 5-6: Metabolic Madness

  • Ataxic 2 yo child

    • Na 152
    • HCO3 12, pH 7.24
    • Ammonia 80
  • Obtunded 25 yo F

    • BP 60s systolic
    • pH 7.16, pCO2 37, pO2 66
    • Hypoglycemia (glucose = 50s)
    • Calcium 6.6


Valproic acid (Depakote)

  • Common anticonvulsant

  • Increasing use in psychiatry

  • Metabolic dysfunction

    • Hypoglycemia
    • Hypocalcemia
    • Elevated ammonia
    • Encephalopathy
  • Coma and rarely cerebral edema

  • Consider hemodialysis if VPA>1000



Cases 7-8: Caustic Cocktails

  • A sulfuric anion gap:

  • 33 yo M ingested "Hot Shot Drain Cleaner" containing 9% sulfuric acid

  • BP 110-120/palp, drooling, in pain

  • ET intubated shortly after arrival

  • Initial Na 143, K 8.1, Cl 97, HCO3 <5,

    • Anion gap >40
  • Lactate 2.1



Caustic Cocktails, continued...

  • Not an anion gap:

  • 43 yo F ingested Lysol Toilet Bowl Cleaner (HCl 8.5-9.5%, pH <1)

  • Pain! Serum CPK 26,812

  • pH 7.19, CO2 24

  • Na 144 Cl 121 HCO3 18.6

    • Anion gap = 4.4


A Final Stumper:

  • A 5 year old Laotian immigrant girl was brought to the ED at 3 AM very lethargic

  • History of nausea and vomiting starting at 1 AM

  • BP 89/42 HR 103 R 16 T 97

  • Pupils 4 mm, skin normal

  • Mouth dry, active peristalsis



Case 9 Continued...

  • According to the father, at 6 pm the previous evening the family had eaten a meal of steamed wild root

  • They collected it near the Berkeley Marina and considered it a tasty substitute for bamboo shoots

  • At 1 AM all 5 family members experienced nausea and vomiting; the 5 yo also had diarrhea



Case 9, Continued...

  • Shortly after admission, the child's pupils were noted to be dilated and poorly reactive

  • Respirations were shallow, and the HR was 65/min

  • pH 6.8 pCO2 21 pO2 220

  • Shortly after, the child had a tonic-clonic seizure



Case 9, Continued...

  • Further Hx:

  • The family said a brother was taking some type of “chest medicine”

  • A family member was sent home to retrieve the bottle….



Common causes of seizures

  • Cocaine/amphetamines

  • Tricyclic antidepressants

  • Bupropion

  • Diphenhydramine

  • Tramadaol

  • Isoniazid (INH)

  • Phenothiazines & antipsychotics



Case, continued

  • The bottle contained erythromycin

  • A blood cyanide level was 6 mg/L

  • The wild root was identified as pampas grass; although usually non-toxic, at certain times of the year it elaborates cyanogenic (cyanide- producing) glycosides.



“MUDPILES” revised?

  • Methanol or metformin

  • Acetaminophen or AKA (“maudespil?”)

  • Uremia

  • DKA or Depakote

  • Phenformin or paracetamol

  • INH, Iron or ibuprofen

  • Lactic acid

  • Ethylene glycol

  • Salicylate or syanide?



A Shorter Mnemonic:

  • SALAD: Lab Test:

    • Salicylate ASA
    • Alcohols Osm
    • Lactic acid Lactate
    • Anuria BUN/Cr
    • DKA Glucose


California Poison Control System

  • Public Hotline: 1-800-876-4766

  • Medical Consult: 1-800-411-8080

  • Nationwide: 1-800-222-1222




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