Amazing, Amusing & Awesome Acidosis Anecdotes And Gnarly Mnemonics Kent R. Olson, md
tarix 17.08.2018 ölçüsü 516 b. #71521
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 Glu 166, BUN 16, Cr 1.5 Measured Osm 331 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 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, 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 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 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 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 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 Dostları ilə paylaş:
