Sam is a 35 y/o alcoholic who is brought to the ER in a comatose state. Sam’s wife tells you that she had an argument in the evening about 5 hrs ago over Sam’s alcohol habits. Sam apparently got mad over the discussion, drove his car and returned an hour ago in a very intoxicated state. Wife called the EMS and rushed him to the ER. On examination Sam is disoriented and hallucinating , Pulse 120 Tm 99, RR 26 BP 126/76. The rest of the physical exam is normal except for stuporos state and alcohol smell. Lab studies revealed Na 130 k 3.4 cl- 95 Hco3 16, Glucose 90 Creatinine 1.6 BUN 45. Blood Ethylalcohol level was 180. Serum osmolarity was 360mg%. ABGs revealed 7.28, Pco2 28, Po2 76 Sao2 93. The next best step in management ?
A) Endotracheal intubation in view of severe acidosis
B) Hemodialysis because this is an acute renal failure causing acidosis
C) Fomepizole because of suspicion of ethylene glycol intoxication
D) Supportive treatment for now because this is an ethylalcohol induced lactic acidosis
E) Bicarbonate drip to reverse the acidosis because this is renal tubular acidosis
a
D. vitals are stable except pulse. but suportive care will work. No need to intubate the patient.
Lol How are the vitals stable Gobariya? PO2 is 76 and he is having severe anion gap metabolic acidosis with a ph of 7.28
d
D
D
this could be ethylene glycol poisoning.
b. Does meet the criteria for hemodialysis
taking a stab
c to protect the kidney…
Answer A
Hypoglycemia and respiratory depression are the 2 most immediate life-threatening complications that result from ethanol intoxication
Assess the airway. If necessary, secure the airway with an endotracheal (ET) tube if the patient is not maintaining good ventilation or if a significant risk of aspiration is observed. Provide respiratory support and mechanical ventilation if needed.
The pH can help in ruling out the co-ingestion of methanol and ethylene glycol, because significant acidemia is associated with those ingestions. However, reports in the literature have documented that the co-ingestion of ethanol and methanol does not cause significant acidosis
ans please ? is it a or c ?
remember the ABCs
you must intubate to protect aspiration and the metobolic acidosis with resp compensation state.Regulation of RR is important. Also IV in both arm, Fluids, Glucose control, Blood alch.levels obtained as well as toxicology.If no improvement more aggressive measures should be taken
osmolar gap >10. Ethylene glycol most likely involved.
I never heard of “we intubate the patient over the low o2 sat !” we simply correct the hypoxia ,with o2 mask or canula , by unstable i think the most imp . thing in assessing a comatose patient is PULSE and BP and RR (imagining the things are fading or not ) , the most imp thing here would be to take care of the patient toxicity which caused this drama and here as we all see we have high anion gap metabolic acidosis ( remember the mnemonic MUDPILE from step1) so i think A difinitely is not the answer
the answer is c , fomepizol is an antidote in suspected methanol or ethylen glycol poisoning , as we see here we have high AG metabolic acidosis , end of discussion
patient is in comatose state. meaning if one did a GCS on him, he would have a score <7. this is an indication for intubation. A comes before anything else.