Case 1: An Acidic Alcoholic n A 44 yo man was found unconscious, with a suicide note and a half-empty bottle of Jim Beam. n BP 110/80HR 110RR 24 n pH.

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

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”

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

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

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

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

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

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….

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

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

Initial labs...

CXR = possible aspiration pneumonia

WBC = 21,000 COHgb = 10% (after receiving 100%

oxygen en route from the scene)

More info...

CT scan = cerebral edema No obvious improvement on 100%

oxygen via ET tube Discussion about HBO –monoplace chamber in the hospital

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

Acute Drug Abuse Emergencies

Common physiologic problems:– Coma– Hypotension or Hypertension– Seizures– Hyperthermia (heat stroke)

Other problems:– Date rape / Assault– Falls / Motor vehicle accidents

Case 1

30 year old man found unconscious, not breathing

Small pupils IV drug abuse paraphernalia

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

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

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...

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

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

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

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

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