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| * toxicology???? |
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[10:25:07 PM] try again: 65-year-old homeless man with a past medical history significant for alcohol abuse was brought to the emergency department by the local ambulance company after being found outside the local strip mall being loud and reckless. Although he was awake, the patient was unable to give any further history. He is well known to the emergency department for multiple visits for alcohol intoxication. Four hours later, the patient was found to be unarousable even after vigorous noxious stimulation. His temperature is 97.9 F with a blood pressure of 110/65 mm Hg, a heart rate of 88/min, and a respiratory rate of 28/min. His eye examination is normal. He has bilateral rales on lung examination, with a minimally distended, nontender abdomen. His arterial blood gas shows: pH 7.15, pCO2 23 mm Hg, and pO2 88 mm Hg. Laboratory studies reveal: sodium 133 mEq/L, chloride 107 mEq/L, serum bicarbonate 10 mEq/L, BUN 34 mg/dL, creatinine 2.2 mg/dL, and glucose 180 mg/dL. The ethanol level is 46 mg dL, with a serum osmolality of 305 mOsm/kg. Urinalysis shows no protein, ketones, or white cells, but crystals are present. What is the definitive treatment for this patient?
(A) Pyridoxine and thiamine
(B) Fomepizole
(C) Hemodialysis
(d) Ethanol infusion
(E) Gastric lavage |
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| * Re:toxicology???? |
| #2018614 |
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ifran this patient has severe ethylene glycol intox with renal insuff etc etc the only trt now is Hemodialysis as soon as possible. |
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| * Re:toxicology???? |
| #2018624 |
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C) Hemodialysis
Explanation:
This patient most likely has ethylene glycol intoxication. He has an elevated anion gap, metabolic acidosis with crystals present in the urine, and renal insufficiency. Hemodialysis should be performed in severe intoxications to remove both the parent compound, as well as the metabolites of ethylene glycol, which are glycolic and oxalic acids. Ethylene glycol intoxication presents with neurologic abnormalities ranging from mild drunkeness to frank coma. If untreated, these changes can progress to pulmonary edema, seizures, and renal failure. Both the acid-base disorder and the clinical symptoms seen in ethylene glycol ingestion are due to the accumulation of the toxic metabolites. Ethylene glycol is metabolized via alcohol dehydrogenase to glycolic and oxalic acids, which are toxic to renal tubules. The key in management in ethylene glycol intoxication is the early recognition. There is no history of visual disturbance, and the examination mentions no retinal findings, which would be consistent with methanol intoxication.
Ethanol is given not as a definitive treatment, but as a temporary measure. Alcohol dehydrogenase has a 10-fold greater affinity for ethanol than other alcohols. Ethanol will prevent the production of the toxic metabolite but will not remove the ethylene glycol from the body. Indications for hemodialysis are a high plasma level of ethylene glycol, the presence of metabolic acidosis, and symptoms of mental status change. Hemodialysis is continued until levels fall below toxic levels. Pyridoxine and thiamine are not the treatment for ethylene glycol intoxication but may serve as adjunctive therapy in any alcoholic patient. Fomepizole works in a fashion similar to ethanol in terms of preventing the production of a toxic metabolite. It does not definitively remove the substance from the body either. Only hemodialysis will do this. |
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