Moderator EMEDPA Posted October 29, 2016 Moderator Share Posted October 29, 2016 open to everyone: 35 yr old female, psych frequent flyer presents via ems with c/c "hyperventilation x 12 hrs". Go. Link to comment Share on other sites More sharing options...
moestown1016 Posted October 29, 2016 Share Posted October 29, 2016 PE Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 29, 2016 Author Moderator Share Posted October 29, 2016 no, thanks for playing Link to comment Share on other sites More sharing options...
moestown1016 Posted October 29, 2016 Share Posted October 29, 2016 no, thanks for playing You're welcome =D Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 29, 2016 Author Moderator Share Posted October 29, 2016 anyone else want to take a stab at it. it's not a typical case. never seen this before, thus the presentation here. questions? work up? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 29, 2016 Author Moderator Share Posted October 29, 2016 ok, I will start to whet some appetites: vs: RR 50 very deep TV bp 126/82 Pulse 112 temp 98.2 sao2 96% RA meds: Prozac, wellbutrin, doxepin chart review shows multiple suicide attempts by multiple means, generally traumatic wdwn fe/caox4/mod rep distress Link to comment Share on other sites More sharing options...
DogLovingPA Posted October 29, 2016 Share Posted October 29, 2016 OD of ?? substance causing acidosis and she's trying to blow off CO2 to increase pH? Your description made me think Kussmaul's but you said it was something you'd never seen. Obviously with her hx a tox screen, salicylate level. Also CBC, CMP, UA, EKG, CXR. ABG? How did it start? Other symptoms? Physical exam? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 30, 2016 Author Moderator Share Posted October 30, 2016 you are on the right track. pt claims abrupt onset awoke her from sleep. no sx other than sob and tachypnea. no pain. no n/v/d. tox screen neg including neg salicylates (what is on a tox screen...hmmmm) cbc nl cmp notable for bicarb of 7(!!!!!) and nl blood sugar. renal fxn nl ua nl ekg ST, otherwise nl cxr nl venous gas ph 7.0 other labs? Link to comment Share on other sites More sharing options...
DogLovingPA Posted October 30, 2016 Share Posted October 30, 2016 etoh level? Concern for methanol or ethylene glycol ingestion? (I'm UC so not sure how you test for those) Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 30, 2016 Author Moderator Share Posted October 30, 2016 alcohol level less than 30 (our nl). lactate 8.6 what is the ddx for a metabolic acidosis? specifically widened gap? what have we ruled out already? Link to comment Share on other sites More sharing options...
DogLovingPA Posted October 30, 2016 Share Posted October 30, 2016 MUDPILES - so methanol, uremia (ruled out), DKA (ruled out), propylene glycol, infection, lactic acidosis, ethylene glycol, salicylates (ruled out) Lactate is 8.6 so lactic acidosis but why? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 30, 2016 Author Moderator Share Posted October 30, 2016 nl cxr, nl ua, no other obvious source for sepsis, no fever so we thought infection unlikely. turns out she drank antifreeze. a lot of it. lactate levels can elevate with this. Tx and antidote? Link to comment Share on other sites More sharing options...
DogLovingPA Posted October 30, 2016 Share Posted October 30, 2016 Well when I worked at the emergency vet we started the dogs on IV drips of grain alcohol. :-) With a pH of 7 I would think she needs dialysis. Do ER's generally carry fomepizole? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 30, 2016 Author Moderator Share Posted October 30, 2016 bicarb drip and fomepizole. did fine. Link to comment Share on other sites More sharing options...
DogLovingPA Posted October 30, 2016 Share Posted October 30, 2016 nice case Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 30, 2016 Author Moderator Share Posted October 30, 2016 medics tried to sell it as simple hyperventilation. 12 hrs? really? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 30, 2016 Author Moderator Share Posted October 30, 2016 also initially considered tca overdose. Link to comment Share on other sites More sharing options...
DogLovingPA Posted October 30, 2016 Share Posted October 30, 2016 I'm surprised they didn't call it a "panic attack" ;-) (not an attack on medics, used to be one too) I thought of TCA overdose when you said she was on doxepin. That generally causes symptoms more in line with respiratory depression, lethargy, convulsions, drowsiness... right? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 30, 2016 Author Moderator Share Posted October 30, 2016 yup. have seen a few really bad tca overdoses and this didn't really fit. no altered mental status. Link to comment Share on other sites More sharing options...
SERENITY NOW Posted October 30, 2016 Share Posted October 30, 2016 nice case. i had a similar case while i was on micu, but it did not end so nicely for the patient. if i remember correctly, ethylene glycol is the one that precipitates calcium crystals (among other badnesses) and sent this guy into acute renal failure that he did not bounce back from and is now dialysis dependent. we weathered the storm as much as could... needed to get all of the fomepizole from 3 surrounding hospitals to be enough to temporize the situation while he remained on dialysis for nearly 24 hours to try to get all of the toxins out. another pearl i remember learning from the toxicologist from the case: one of the metabolites of the ethylene glycol is structurally similar to lactate, causing the more nonspecific lactate tests to be falsely elevated. was there any discrepancy between the lactate you maybe got on the venous blood gas vs specific serum test for it? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 30, 2016 Author Moderator Share Posted October 30, 2016 we had several confirmations of acidosis: clinical picture w/ hyperventilation, etc venous blood gas ph 7 lactate 8.6 cmp bicarb 7. I forgot to mention above I also checked a ck for rhabdo early on. it was nl. Link to comment Share on other sites More sharing options...
karebear12892 Posted October 30, 2016 Share Posted October 30, 2016 PA student here - I saw one case of antifreeze ingestion when I was a medical scribe. There was nothing in his initial H&P to suggest suicidal ideation/toxic ingestion. The diagnosis was confirmed by obtaining (in addition to the labs already mentioned) a serum osmolality level and a urinalysis to detect the presence of calcium oxalate crystals. The ED doctor called the lab and asked the technician to specifically look for these in the urine, and when she confirmed they were there, he knew he had his diagnosis. Definitely one of the coolest cases I've seen! Link to comment Share on other sites More sharing options...
bk84nation Posted November 8, 2016 Share Posted November 8, 2016 Worked with a doc who handled a similar case. Elderly patient came in with similar presentation. Was poisoned with antifreeze. Wide osmolar gap. Serum osmolality was key lab. Great case but pt did not make it :( Link to comment Share on other sites More sharing options...
polarbebe Posted November 16, 2016 Share Posted November 16, 2016 After metabolizing the poison (later in the course after ingestion), serum osmolarity will be minimally elevated or normal but an anion gap remains. If history is suggestive, normal osmolar gap does not rule out toxic ingestion. "After the bulk of the methanol has been metabolized, little or no increase in serum osmolality will be present, whereas the serum anion gap can be strikingly increased and the serum HCO3− markedly depressed" http://m.cjasn.asnjournals.org/content/3/1/208.full Link to comment Share on other sites More sharing options...
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