Transcript Case 5 - Tripod.com

A lady in coma
Law Chi Yin
PYNEH
A lady in coma
► 98/F
► Found
unconscious in bed at 5:00 am
► No special complain in recent days
► No history of injury
► Brought in by ambulance
► Accompany with her son who is Chinese
medicine practitioner
A lady in coma
► Her
son showed you a bottle of antiseptic
solution
► She was suspected drinking the solution last
night
A lady in coma
► No
external wound
► GCS 3/15
► BP 120/68 mmHg, pulse 128 bpm
► Temp 36.8oC,
► RR 22 / min
► SpO2 91% in 100% O2
A lady in coma
► She
had skin eczema
► requiring home skin care with antiseptic
solution
► She got history of suicidal attempt before
► No other empty bottles of pills,
► No win bottle at her home
► No history of DM
A lady in coma
► She
was intubated in AED
► CXR showed lung fields haziness
► She was admitted to medical ward for toxic
alcohol intoxication
A lady in coma
► Investigation





Na
K
Cl
Urea
Cr
140
3.3
107
8.5 (<6.5)
203(<97)
► Investigation
 WBC
 Ca
 Amylase
 Sugar
29.3
2.13(2.2-2.6)
285(<125)
20.5
A lady in coma
► Investigation






pH
7.236
pCO2
3.04
pO2
39.34
HCO3
9.5 (20-26)
Base excess -15.9 (-3 to 3)
O2 saturation
99.6
A lady in coma
► Investigation
 Serum osmolality 352 mOsm/kg(289-308)
 Serum toxicology
►Serum
level of paracetamol, salicylates and ethanol
was normal
 Urine tests
►Negative
for barbiturates, benzodiazepines,
cannabinoids and opiates
A lady in coma
► Problems




Coma
Suspected aspiration pneumonia
Metabolic acidosis
Increase serum osmolality
A lady in coma
► Anion
gap
=Na + k - Cl –HCO3
=140+3.3-107-9.5
=26.8 (normal 8-12)
► Elevated
AG
A lady in coma
► Osmolality
gap
=measure osmolality – (2x Na + urea + glucose)
=352-(140x2 +8.5 -20.5)
=352-309
=43 (normal <10)
► Elevated
OG
A lady in coma
► DDx
of anion gap metabolic acidosis
 Mudpiles:
►methanol,
►Uremia,
►DKA,
►Paraldehyde,
►INH/Iron,
►lactate,
►ethylene
glycol,
►Salicylates
A lady in coma
► DDx
of anion gap metabolic acidosis
 Kult:
►Ketones
(DKA, alcoholic, salicylates)
►Uremia
►Lactate
(hypoxia, shock, CN poisoning, seizures, liver
failure)
►Toxic alcohol
A lady in coma
► DDx
of increase osmolality gap
 Medie
►Methanol/
metformin lactic acidosis
►Ethylene glycol
►DKA/ diuretic (mannitol)
►Isopropyl alcohol
►Ethanol
A lady in coma
► The
bottle contained 75 % isopropyl alcohol
► His son estimated that her mother might
drink up to 50 ml of the solution
► She had drunk the solution 8 hours before
she presented to emergency room
Isopropyl alcohol
Isopropyl alcohol
► Isopropanol
or 2-propanol
► Skin disinfectant, and popularly name as
rubbing alcohol
► Commonly used as a window cleaner and
paint remover and industry solvent
► Gasoline additive for dissolving water or ice
in fuel lines
Isopropyl alcohol
Isopropyl alcohol
► It
metabolizes to acetone in the liver by
alcohol dehydrogenase.
► 80% absorbed dose is excreted by the
kidneys as acetone
► 20% being excreted unchanged.
► The acetone is also excreted in the lungs,
saliva, and gastric juices.
Acetone
► Acetone,
also called dimethyl ketone
► An excellent solvent for oils and greases
► It is one of the least toxic of the many
organic solvents used
► Clinical effects to human body is similar to
ethanol.
Isopropyl alcohol
► It
is two-three times more potent than
ethanol as a CNS depressant.
► The breakdown product, acetone, is also a
CNS depressant.
► Doses of above 20 ml of rubbing alcohol
(70% solution) may produce toxic effects.
Isopropyl alcohol
intoxication
► Poisoning
can occur through skin absorption,
oral ingestion, or inhalation
► Symptoms of intoxication occur within 30
minutes
► Symptoms include:
 flushing, headache, dizziness,
 mental depression, nausea, vomiting
 anesthesia, and coma
Isopropyl alcohol
intoxication
► Symptoms
may occur as 1 ml/kg of a 70%
solution.
► The lethal dose may be as low as 240 ml (2
to 4 ml/kg).
► Death has been reported at a blood level of
150 mg/dl (25 mmol/l)
► Survival after dialysis has been reported at
levels as high as 560 mg/dl
Isopropyl alcohol
intoxication
► No
initial excitatory phase (well recognized
with ethanol intoxication)
► odor of acetone (sweet ketotic scent)
► Myocardial depression and severe
hypotension in large dose intoxication
► Less common :
 renal tubular necrosis, hemolytic anemia, acute
myopathy, and hypothermia
Isopropyl alcohol
intoxication
► Has
greater osmolality gap in four toxic
alcohols
► Has only mild anion gap metabolic acidosis
(similar to ethanol intoxication)
► Exception is for patient has hypotension,
hypoxia, etc
► Similar to ethanol, It has significant
hypoglycemic effect.
Treatment of Isopropyl alcohol
intoxication
► ABC
care
► Close observation of vital signs
► Supportive care
► Prevention of complications
► DDx
Treatment of Isopropyl alcohol
intoxication
► Gastric
lavage and charcoal of a large,
recent dose of isopropanol
► Hemodialysis for patients with coma and
hypotension with or without a level of 400500 mg/dl.
► No antidote
Paediatric consideration
► Case
reports of isopropyl alcohol
intoxication
 accidentally ingest
 Dermal/inhalation exposure in children during
isopropyl alcohol sponging for control of fever
Outcome
► She
died few days later
► Serum level of isopropyl alcohol was not
checked
► Likely
causes of death
 Isopropyl alcohol intoxication
 Complicated with aspiration pneumonia and
renal failure