Maryland ACEP Chapter Educational Conference & Annual … · 2020-02-26 · Presentation HPI:...
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Maryland ACEP Chapter Educational Conference & Annual Meeting March 12, 2020 FACULTY: Maria ‘Marysia’ Lawrynowicz, M.S., MD PRESENTATION Alcoholics Anonymous DESCRIPTION Recognizing alcoholic ketoacidosis as the etiology of your patient’s symptoms is difficult as the presentation is varied and lab interpretation is nuanced. This presentation will provide several salient points to help you understand the relevant pathophysiology as it relates to diagnosis and treatment of the disease. OBJECTIVES • Describe the pathophysiology of alcoholic ketoacidosis as it relates to diagnosis and treatment. • Identify the constellation of lab values that may be seen in alcoholic ketoacidosis. • Brief case presentation. • Pathophysiology of AKA. • Diagnostic results. • Treatment. DISCLOSURE No significant financial relationships to disclose.
Transcript of Maryland ACEP Chapter Educational Conference & Annual … · 2020-02-26 · Presentation HPI:...
Maryland ACEP Chapter Educational Conference & Annual Meeting
March 12, 2020
FACULTY: Maria ‘Marysia’ Lawrynowicz, M.S., MD PRESENTATION Alcoholics Anonymous DESCRIPTION Recognizing alcoholic ketoacidosis as the etiology of your patient’s symptoms is difficult as the presentation is varied and lab interpretation is nuanced. This presentation will provide several salient points to help you understand the relevant pathophysiology as it relates to diagnosis and treatment of the disease. OBJECTIVES
• Describe the pathophysiology of alcoholic ketoacidosis as it relates to diagnosis and treatment.
• Identify the constellation of lab values that may be seen in alcoholic ketoacidosis.
• Brief case presentation.
• Pathophysiology of AKA.
• Diagnostic results.
• Treatment. DISCLOSURE No significant financial relationships to disclose.
AlcoholicsAnonymousMARYSIA (MARIA)LAWRYNOWICZ,PGY2MGUH/MWHC
HPI53yoFp/wCP andLBP.
Shehasnotbeentakinghermedsoreatingduetothepain,buthasbeendrinkingalcohol.
Shewasfounddownhypoxic andtachycardicwithAMS.
HPIcont.PMHx: NONEperpatient
BUT,perpaperwork….COPD,atrialfibrillation,atrialflutter,GERD,obesitys/pgastricbypasswithrevision,spinalstenosiss/pL4laminectomyandL4-5discectomy,anxiety,depression
PEVS T:36C(Oral) HR:109 RR:18BP:149/69 SpO2:90%
General:Chronicallyillappearing.Shiftinginbed.HEENT:Edentulous.DryMM.Resp:Tachypneic.CTA.CV:Tachycardic.Abdomen:Soft,+diffuseTTP.BS+Neuro:Difficulttounderstandspeech. NoFND.Skin:Coolandclammy.
Labcalled…‘nonoit’sL-A-W-R-Y...’
pH7.14 pCO218 HCO28Expectedfeedbackonpresentationafterbringingupacid-basedisorders👎 👎 👎
Aniongapmetabolicacidosis
ANIONGAP:Na– (Cl+CO2)=133– (94+8)
AlcoholicketoacidosisAKA THEOTHERKETOACIDOSIS
Roadmap§ Casepresentation✅§ Pathophysiology§ Presentation§ Diagnosticresults§ Treatment§ Conclusion
PathophysiologyofAKA
https://www.emra.org/emresident/article/understanding-alcoholic-ketoacidosis/
1. Ketotic state
2. IncreasedNADH
3. Adrenergicstate
1.Ketotic stateSTARVATION
LIPOLYSIS
KETONES
2.IncreasedNADH
3.Adrenergicstate
Roadmap§ Casepresentation✅§ Pathophysiology✅§ Presentation§ Diagnosticresults§ Treatment§ Conclusion
PresentationHPI:
§ PMHx ofETOHuse
§ Recentcessationofbingedrinking
§ +/- Gastritis
§ +/- Pancreatitis
§ +/- Aspirationpneumonia
Symptoms:
§ Nausea/vomiting
§ Abdominalpain
§ Dehydration
Wrenn,KDetal.Thesyndromeofalcoholketoacidosis.AmJMed. 1991Aug;91(2):119-28.
DDx§ Toxicalcoholingestion§ Alteredsensorium§ Initialosmolar gapà aniongap
§ Diabeticketoacidosis§ Alteredsensorium§ BG>250usually
§ Starvationketosis§ Bicarbonateusuallynotaslow
§ Lacticacidosis>4
DKA AKA Fasting
Bicarb <10possible
<10possible >18
Glucose High Low– mildhigh
Low–normal
Ketonuria + +/- +
https://www.emra.org/emresident/article/understanding-alcoholic-ketoacidosis/
Roadmap§ Casepresentation✅§ Pathophysiology✅§ Presentation✅§ Diagnosticresults§ Treatment§ Conclusion
Labvalues
HYPER– glycemia,osmolarity
HYPO– ETOH,kalemia,phosphatemia,magnesemia
Wrenn,KDetal.Thesyndromeofalcoholketoacidosis.AmJMed. 1991Aug;91(2):119-28.
KETONES
KETONES
KETONES
DeltadeltadeltaAKAw/ABG(n=40)23%aniongapmetabolicacidosis…therestwasmixed
Wrenn,KDetal.Thesyndromeofalcoholketoacidosis.AmJMed. 1991Aug;91(2):119-28.
Roadmap§ Casepresentation✅§ Pathophysiology✅§ Presentation✅§ Diagnosticresults✅§ Treatment§ Conclusion
Treatment§ 1.IsotonicANDdextrosecontainingfluids§ 2.Thiamine100mgIVorIM§ 3.Repleteallelectrolytes§ 4.Treatalcoholwithdrawal§ 5.Treatcause
Milleretal.Treatmentofalcoholicacidosis:theroleofdextroseandphosphorus. ArchInt Med1978;138:67-72.
Roadmap§ Casepresentation✅§ Pathophysiology✅§ Presentation✅§ DifferentialDx✅§ Diagnosticresults✅§ Treatment✅§ Conclusion
???
Pearlsandpitfalls§ Recognizingthisishalfthebattle
§ Listentothestory
§ Knowthelimitationsofyourlabstudies
§ Givevolumewithdextrose(andthiamine)!
§ Beaninternist…repletethelytes
§ Treatprecipitatingfactor
§ Casereportsdonothavetobethatinteresting
ReferencesBoutin C,Laskine M.KetoacidosisinaNon-diabeticAdultwithChronicEtOH Consumption.JClin MedRes2016;8(12):919-920.
Chandrasekara H.etal.Ketoacidosisisnotalwaysduetodiabetes.BMJCaseRep2014.doi:10.1136/bcr-2013-203263
Coopermanetal.Clinical studiesofalcoholicketoacidosis.Diabetes1974:23:433-9.
HowardRandBokhari S.Alcoholicketoacidosis.Treasure Island(FL): StatPearlsPublishing;2018Jan-.
Miller etal.Treatmentofalcoholic acidosis:theroleofdextroseandphosphorus. ArchInt Med1978;138:67-72.
Nooretal.Alcoholicketoacidosis:acasereportandreviewoftheliterature.Oxf MedCaseReports2016(3)31-33.
Palmiere etal.Postmortenbiochemistry insuspectedstarvation-inducedketoacidosis.JForensicLegMed 2016(42):51-55.
Schabelman E,Kuo D.Glucosebeforethiamine forWernicke encephalopathy:aliterature review. JEmerg Med 2010;42:488.
VonGeijer L,Ekelund M.Ketoacidosisassociatedwithlow-carbohydratedietinanon-diabetic lactatingwoman:acase report.JMedCaseRep2015;9:224.
Wardi G,O’ConnellC.UnderstandingAlcoholicKetoacidosis.EMRA.https://www.emra.org/emresident/article/understanding-alcoholic-ketoacidosis/.
Wrenn,KDetal.Thesyndromeofalcoholketoacidosis.AmJMed. 1991Aug;91(2):119-28.
