Question of the week # 52

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

23 Responses

  1. D. vitals are stable except pulse. but suportive care will work. No need to intubate the patient.

  2. d

  3. D

  4. this could be ethylene glycol poisoning.

  5. b. Does meet the criteria for hemodialysis

  6. taking a stab
    c to protect the kidney…

  7. 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

  8. ans please ? is it a or c ?

  9. 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

  10. osmolar gap >10. Ethylene glycol most likely involved.

  11. 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

  12. 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

  13. 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.

  14. This man has ethylene alcohol poisoning. Evidence?
    1. Osmolar gap is 79 (normal < 10)
    2. Anion gap is 19 (normal 3-11)
    Alcohol intoxication alone can not give such huge difference.
    Urgent Fomepizole is needed stat. It is the next best step in management. Why?
    1. We don't know how much toxic alcohol is still in this man's blood even though it would be expected to be lower than the interval when the osmolar gap and anion gap were normal. It should be continued until blood ethylene glycol level is found to be less than 20mg%. Empirical treatment with fomepizole is a standard practice pending lab results. It is also safer than the substitute, which is alcohol drip.
    2. He is still in stage one entering into stage two. We must prevent or stop further activity of alcohol dehydrogenase as the involvement of the cardiopulmonary function is a more severe disease. Its been 5 hours since he was last seen (by his wife). It takes 4 hours for ethylene glycol to reach peak concentration. He must still have high levels of toxic alcohol. Fomepizole will help.
    3. This patient does not have lab readings that will necessitate hemodialysis, or Hco3 therapy. This patient does not have severe acidosis. These options set in when PH fails below 7.0 or 7.1.

    My answer is option C.

    Why not endotracheal intubation?
    1. I consider that the neurological findings are the result of stage 1 of ethylene glycol byproducts toxicity. At ethyl alcohol blood level of 140mg%, we do not expect coma. Loss of consciousness, CNS depression is expected at blood alcohol levels of 3oo- 339mg%. His delirium and stuporous state should improve with Fomepizole. Stupor is not full blown coma. Gag reflexes are intact in stupor. ETI is not neccessary.
    2. Secondly, this patient has strong cardiopulmonary reflexes evident by the 02 sat of 93 despite pCO2 of 28 and pO2 of 76. And he is able to maintain normal vital signs despite the severe metabolite stress challenge. He does not need mechanical ventilation. Some of us are concerned that he may aspirate since we saw at the beginning of the question, he was comatose. But on physical exam he is stuporous not comatous. His gag reflexes are therefore intact.
    3. This patient does not have severe metabolic acidosis. It is not justified to do endotracheal intubation in view to this untrue assessment.

    helpful: stage one is neurological, stage two is cardiopulmonary (including ARDS), Stage three is renal.
    Must do – serum calcium, QT interval, electrolyte, glucose
    Must include pyridoxine and thiamine in treatment. These agents aid in detoxification of harmful byproducts of ethylene glycol.
    Must monitor toxic alcohol level
    Delay in primary treatment of ethylene glycol poisoning pending results is not acceptable.

  15. I would pick C as well, I also like Adnan’s response. Dr. Red, do you have the official answer or any final thoughts?

    • ans c
      no need immediate intubation because saturation 93%.
      a not correct then think about toxin level ….then renal insufficiency
      so my ans is c

      • Yes – it is always important to identify the reversible causes of Stupor/ coma so antidote measures can be administered immediately. For example, Hypoglycemia would respond quickly to dextrose administration. Similarly, this is a case of Ethylene glycol poisoning which would respond fairly quickly to Fomepizole administration. His oxygen saturation is good. Airway needs to be protected with suction since there is risk of aspiration. But intubation will be required if there is no gag reflex or the patient is very hypoxic despite non-invasive oxygenation. Intubation may also be required if the altered mental status/ coma is not rapidly reversible and patient continues to be persistently comatose. In this case, his mental status may be rapidly restored after Fomepizole. So, first step is administering Femepizole.

        Within three hours of starting fomepizole, inhibition of metabolite production and resolution of acidosis occurs. Anion gap is normalized within four hours. If fomepizole therapy is initiated before a rise in the serum creatinine concentration, damage to the kidney can be avoided. When compared with ethanol, the advantages of fomepizole include a slower rate of excretion by the kidneys, lack of CNS depression or hypoglycemia, and easier maintenance of effective plasma levels.

  16. Lovely piece of brainstorming.Very well explained. Liking every bit of it.

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