‘To Alcohol! The Cause of, and Solution to, All of Life's Problems’

A 37-year-old woman is brought into the emergency department by EMS after being found down next to a bottle of an unknown substance. (See photo.) Her family said she was initially tearful and repeatedly mumbling, “I’m sorry,” and became progressively less responsive.   She was obtunded and intubated for airway protection upon arrival to the ED. Her initial vital signs were a temperature of 98.8°F, heart rate 110 bpm, blood pressure 187/118 mm Hg, respiratory rate 22 bpm, and pulse oximetry 98% on ventilator. Initial ABG reveals a pH 6.89, pCO2 16, pO2 174, and bicarbonate 3.1. Pertinent lab results include a metabolic panel with an anion gap of 24, creatinine 1.23, ammonia of 103, and a positive urine drug screen for THC.       What is the differential diagnosis for a patient with a large anion gap? For this patient, we considered the possible etiologies included in the mnemonic MUDPILES.   M       Methanol, metformin U        Uremia D        DKA, AKA, or any ketoacidosis P        Paracetamol, paraldehyde I         Iron, isoniazid L        Lactate E        Ethylene glycol, ethanol S        Salicylates   Acetaminophen, salicylate, and ethanol levels were negative. Initial lactate is 5.6 mmol/L, and serum osmolality is 354. Her metabolic panel is below:     What is this patient’s osmolal gap? Osmolal gap= serum osmolality - calculated osmolality [(2 x serum Na) + (serum glucose/18) +...
Source: The Tox Cave - Category: Emergency Medicine Tags: Blog Posts Source Type: blogs