A lady in coma Law Chi Yin PYNEH. A lady in coma ► 98/F ► Found unconscious in bed at 5:00 am...

A lady in comaA lady in coma

Law Chi YinLaw Chi Yin

PYNEHPYNEH


►98/F98/F►Found unconscious in bed at 5:00 amFound unconscious in bed at 5:00 am►No special complain in recent daysNo special complain in recent days►No history of injuryNo history of injury►Brought in by ambulanceBrought in by ambulance►Accompany with her son who is Accompany with her son who is

Chinese medicine practitionerChinese medicine practitioner


►Her son showed you a bottle of Her son showed you a bottle of antiseptic solutionantiseptic solution

►She was suspected drinking the She was suspected drinking the solution last nightsolution last night


►No external woundNo external wound►GCS 3/15GCS 3/15►BP 120/68 mmHg, pulse 128 bpmBP 120/68 mmHg, pulse 128 bpm►Temp 36.8Temp 36.8ooC, C, ►RR 22 / minRR 22 / min►SpOSpO22 91% in 100% O 91% in 100% O22


►She had skin eczemaShe had skin eczema►requiring home skin care with requiring home skin care with

antiseptic solution antiseptic solution ►She got history of suicidal attempt She got history of suicidal attempt

beforebefore►No other empty bottles of pills, No other empty bottles of pills, ►No win bottle at her homeNo win bottle at her home►No history of DMNo history of DM


►She was intubated in AEDShe was intubated in AED►CXR showed lung fields hazinessCXR showed lung fields haziness►She was admitted to medical ward for She was admitted to medical ward for

toxic alcohol intoxication toxic alcohol intoxication


► InvestigationInvestigation NaNa 140140 KK 3.33.3 ClCl 107107 UreaUrea 8.5 (<6.5)8.5 (<6.5) CrCr 203(<97)203(<97)

► InvestigationInvestigation WBC WBC 29.329.3 CaCa 2.13(2.2-2.6)2.13(2.2-2.6) AmylaseAmylase

285(<125)285(<125) SugarSugar20.520.5


► InvestigationInvestigation pHpH 7.2367.236 pCO2pCO2 3.043.04 pO2pO2 39.3439.34 HCO3HCO3 9.5 (20-26)9.5 (20-26) Base excessBase excess -15.9 (-3 to 3)-15.9 (-3 to 3) O2 saturationO2 saturation 99.699.6


► InvestigationInvestigation Serum osmolality Serum osmolality 352 mOsm/kg(289-352 mOsm/kg(289-

308)308) Serum toxicologySerum toxicology

►Serum level of paracetamol, salicylates and Serum level of paracetamol, salicylates and ethanol was normalethanol was normal

Urine testsUrine tests►Negative for barbiturates, benzodiazepines, Negative for barbiturates, benzodiazepines,

cannabinoids and opiatescannabinoids and opiates


►Problems Problems ComaComa Suspected aspiration pneumoniaSuspected aspiration pneumonia Metabolic acidosisMetabolic acidosis Increase serum osmolalityIncrease serum osmolality


►Anion gapAnion gap=Na + k - Cl –HCO3=Na + k - Cl –HCO3=140+3.3-107-9.5=140+3.3-107-9.5=26.8 (normal 8-12)=26.8 (normal 8-12)

►Elevated AGElevated AG


►Osmolality gapOsmolality gap=measure osmolality – (2x Na + urea + =measure osmolality – (2x Na + urea +

glucose)glucose)

=352-(140x2 +8.5 -20.5)=352-(140x2 +8.5 -20.5)

=352-309=352-309

=43 (normal <10)=43 (normal <10)

►Elevated OG Elevated OG


►DDx of anion gap metabolic acidosisDDx of anion gap metabolic acidosis Mudpiles: Mudpiles:

►methanol, methanol, ►Uremia, Uremia, ►DKA, DKA, ►Paraldehyde, Paraldehyde, ►INH/Iron, INH/Iron, ►lactate, lactate, ►ethylene glycol, ethylene glycol, ►SalicylatesSalicylates


►DDx of anion gap metabolic acidosis DDx of anion gap metabolic acidosis Kult: Kult:

►Ketones (DKA, alcoholic, salicylates)Ketones (DKA, alcoholic, salicylates)►UremiaUremia►Lactate (hypoxia, shock, CN poisoning, Lactate (hypoxia, shock, CN poisoning,

seizures, liver failure)seizures, liver failure)►Toxic alcohol Toxic alcohol


►DDx of increase osmolality gapDDx of increase osmolality gap MedieMedie

►Methanol/ metformin lactic acidosisMethanol/ metformin lactic acidosis►Ethylene glycolEthylene glycol►DKA/ diuretic (mannitol)DKA/ diuretic (mannitol)►Isopropyl alcoholIsopropyl alcohol►EthanolEthanol


►The bottle contained 75 % isopropyl The bottle contained 75 % isopropyl alcoholalcohol

►His son estimated that her mother His son estimated that her mother might drink up to 50 ml of the solutionmight drink up to 50 ml of the solution

►She had drunk the solution 8 hours She had drunk the solution 8 hours before she presented to emergency before she presented to emergency roomroom

Isopropyl alcoholIsopropyl alcohol


► Isopropanol or 2-propanol Isopropanol or 2-propanol ►Skin disinfectant, and popularly name Skin disinfectant, and popularly name

as rubbing alcohol as rubbing alcohol ►Commonly used as a window cleaner Commonly used as a window cleaner

and paint remover and industry and paint remover and industry solvent solvent

►Gasoline additive for dissolving water Gasoline additive for dissolving water or ice in fuel lines or ice in fuel lines


► It metabolizes to acetone in the liver It metabolizes to acetone in the liver by alcohol dehydrogenase. by alcohol dehydrogenase.

►80% absorbed dose is excreted by the 80% absorbed dose is excreted by the kidneys as acetonekidneys as acetone

►20% being excreted unchanged. 20% being excreted unchanged. ►The acetone is also excreted in the The acetone is also excreted in the

lungs, saliva, and gastric juices. lungs, saliva, and gastric juices.

AcetoneAcetone

►Acetone, also called dimethyl ketoneAcetone, also called dimethyl ketone►An excellent solvent for oils and An excellent solvent for oils and

greases greases ► It is one of the least toxic of the many It is one of the least toxic of the many

organic solvents usedorganic solvents used►Clinical effects to human body is Clinical effects to human body is

similar to ethanol.similar to ethanol.


► It is two-three times more potent than It is two-three times more potent than ethanol as a CNS depressant.ethanol as a CNS depressant.

►The breakdown product, acetone, is The breakdown product, acetone, is also a CNS depressant. also a CNS depressant.

►Doses of above 20 ml of rubbing Doses of above 20 ml of rubbing alcohol (70% solution) may produce alcohol (70% solution) may produce toxic effects. toxic effects.

Isopropyl alcohol Isopropyl alcohol intoxicationintoxication

►Poisoning can occur through skin Poisoning can occur through skin absorption, oral ingestion, or inhalation absorption, oral ingestion, or inhalation

►Symptoms of intoxication occur within Symptoms of intoxication occur within 30 minutes 30 minutes

►Symptoms include:Symptoms include: flushing, headache, dizziness, flushing, headache, dizziness, mental depression, nausea, vomitingmental depression, nausea, vomiting anesthesia, and coma anesthesia, and coma


►Symptoms may occur as 1 ml/kg of a Symptoms may occur as 1 ml/kg of a 70% solution.70% solution.

►The lethal dose may be as low as 240 The lethal dose may be as low as 240 ml (2 to 4 ml/kg). ml (2 to 4 ml/kg).

►Death has been reported at a blood Death has been reported at a blood level of 150 mg/dl (25 mmol/l)level of 150 mg/dl (25 mmol/l)

►Survival after dialysis has been Survival after dialysis has been reported at levels as high as 560 mg/dl reported at levels as high as 560 mg/dl


►No initial excitatory phase (well No initial excitatory phase (well recognized with ethanol intoxication)recognized with ethanol intoxication)

►odor of acetone (sweet ketotic scent)odor of acetone (sweet ketotic scent)►Myocardial depression and severe Myocardial depression and severe

hypotension in large dose intoxicationhypotension in large dose intoxication►Less common :Less common :

renal tubular necrosis, hemolytic anemia, renal tubular necrosis, hemolytic anemia, acute myopathy, and hypothermia acute myopathy, and hypothermia


►Has greater osmolality gap in four toxic Has greater osmolality gap in four toxic alcoholsalcohols

►Has only mild anion gap metabolic Has only mild anion gap metabolic acidosis (similar to ethanol intoxication) acidosis (similar to ethanol intoxication)

►Exception is for patient has Exception is for patient has hypotension, hypoxia, etchypotension, hypoxia, etc

►Similar to ethanol, It has significant Similar to ethanol, It has significant hypoglycemic effect.hypoglycemic effect.

Treatment of Isopropyl alcohol Treatment of Isopropyl alcohol intoxicationintoxication

►ABC careABC care►Close observation of vital signs Close observation of vital signs ►Supportive careSupportive care►Prevention of complicationsPrevention of complications►DDxDDx

Treatment of Isopropyl alcohol Treatment of Isopropyl alcohol intoxicationintoxication

►Gastric lavage and charcoal of a large, Gastric lavage and charcoal of a large, recent dose of isopropanolrecent dose of isopropanol

►Hemodialysis for patients with coma Hemodialysis for patients with coma and hypotension with or without a and hypotension with or without a level of 400-500 mg/dl. level of 400-500 mg/dl.

►No antidoteNo antidote

Paediatric considerationPaediatric consideration

►Case reports of isopropyl alcohol Case reports of isopropyl alcohol intoxicationintoxication accidentally ingest accidentally ingest Dermal/inhalation exposure in children Dermal/inhalation exposure in children

during isopropyl alcohol sponging for during isopropyl alcohol sponging for control of fever control of fever

OutcomeOutcome

►She died few days laterShe died few days later►Serum level of isopropyl alcohol was Serum level of isopropyl alcohol was

not checkednot checked

►Likely causes of deathLikely causes of death Isopropyl alcohol intoxicationIsopropyl alcohol intoxication Complicated with aspiration pneumonia Complicated with aspiration pneumonia

and renal failureand renal failure

A lady in coma Law Chi Yin PYNEH. A lady in coma ► 98/F ► Found unconscious in bed at 5:00 am...

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Transcript of A lady in coma Law Chi Yin PYNEH. A lady in coma ► 98/F ► Found unconscious in bed at 5:00 am...