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Case 1: An Acidic Alcoholic

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 pCO 2 22 pO 2 88 Na 140 K 3.8 Cl 106 HCO 3 18 ETOH 0.18 gm/dL. Case 2: A Gapped Gipper. 30 yo M found comatose

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Case 1: An Acidic Alcoholic

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  1. 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

  2. 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”

  3. Cases 3-4: 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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….

  9. Seizures and acidosis • A 15 year old high school student recently immigrated from Laos • Had 3 seizures at home • Unconsicous • pH 6.9 pCO2 34

  10. Smoke inhalation • A 54 year old alcoholic was found in his smoke-filled trailer by firefighters • obtunded, combative • soot on face and in nose • BP 160/100, HR 110/min, RR 22/min • EtOH = 0.08 g/dL

  11. Initial labs... • CXR = possible aspiration pneumonia • WBC = 21,000 • COHgb = 10% (after receiving 100% oxygen en route from the scene)

  12. More info... • CT scan = cerebral edema • No obvious improvement on 100% oxygen via ET tube • Discussion about HBO • monoplace chamber in the hospital

  13. Now what? • Re-examination: • rectal T 38.5 C • stiff neck? Or irritation due to ET tube? • Revisited the ATOMIC mnemonic: • LP: purulent pneumococcal meningitis!! • Treated with IV antibiotics, no HBO

  14. Acute Drug Abuse Emergencies • Common physiologic problems: • Coma • Hypotension or Hypertension • Seizures • Hyperthermia (heat stroke) • Other problems: • Date rape / Assault • Falls / Motor vehicle accidents

  15. Case 1 • 30 year old man found unconscious, not breathing • Small pupils • IV drug abuse paraphernalia

  16. Opioid Overdose • Causes: • IV heroin most common • Other sources: codeine, etc. • Activate opioid receptors in brain: • Sleepiness • Depressed respiratory drive • Treatment: • Support breathing, give oxygen • Naloxone: specific antidote

  17. Case 2 • 23 year old found on floor at a dance party • Unresponsive to pain • Occasional muscle twitching or seizure-like activity • Barely breathing • No response to IV naloxone • Awake in 2 hours

  18. GHB • Gamma hydroxy butyrate • Short-acting anesthetic agent • Rapid onset of deep coma • Lasts 2-4 hours • Precursors and chemical relatives • Gamma butyrolactone (GBL), 1,4- butanediol, tetramethylene glycol, or 2(3H)-Furanone di-hydro • Revitalize Plus, Serenity, Enliven, GHRE, SomatoPro, NRG3, Thunder Nectar...

  19. Case 3 • Another young man on the dance floor, having multiple seizures • In ER: • Unresponsive • BP 90/60, HR 140/min • Rectal T 106.5 F • Remains in deep coma, develops multiple organ failure, dies after 2 days in the hospital

  20. Stimulant intoxication • Many causes: • Methamphetamine (“crystal”, “crank”) • MDMA (“ecstasy”) • Cocaine • Various OTC products (ephedrine, PPA, caffeine, herbal and nutritional supplements) • Central sympathetic system stimulation • Activation of peripheral CV receptors

  21. Stimulants, cont. • Clinical findings: • Euphoria, alertness • Paranoia, agitation • Seizures • Increased heart rate, blood pressure • Hyperthermia is BIG life threat • Brain damage • Hypotension • Mulitple organ failure

  22. Case 4 • 17 year old found at the bottom of the staircase • Had been “huffing” gas from a can of computer key board cleaner. • 911 was called - police arrived in 2 minutes and found him pulseless, not breathing • Resuscitated but declared brain dead and expired 2 days later

  23. Solvent abuse • Variety of solvents and gases: • Toluene, xylene (in glues, paints, etc) • Trichloroethylene (“White-out”) • Freon • Nitrous oxide • Butane • Main danger: cardiac arrhythmia • Long-term brain damage with toluene, nitrous oxide

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