Tony Pizon, M.D. Associate Professor Division of Medical Toxicology University of Pittsburgh

Transcription

1 Tony Pizon, M.D. Associate Professor Division of Medical Toxicology University of Pittsburgh

2 50 yo man was found confused in his garage. He has been depressed but no other history is known. He has no known medical problems and is on no medications.

3 Vitals: T 37.0C, P 125, R 32, BP 100/60 HEENT: Dry oral mucosa. Lungs: Clear. CV: Tachy. GI: Soft, normal bowel sounds. Skin: Dry without lesions Neuro: Confused and requiring restraints. Moves all ext equally, good tone. +1 DTR s, CN II-XII intact.

4 Laboratory Findings ETOH 0 Sal 0 APAP 0 CarboxyHbg 2% Osm 330 (Calc Osm 292) Lactate 24 PT 11.5 ph 7.18/pCO 2 8/paO 2 132/HCO 3 3

5 What is the diagnosis?

6 -OH -OH -OH C-C-OH C-C-C 4. C-OH 2. C-C-C 5. HO-C-C-OH

7 Where does is come from? Automotive antifreeze VS

8 Pharmacology Absorption Rapid and immediate (Like ethanol) ~100% bioavailable (some mucosal metabolism) Metabolism Elimination

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10 Pharmacology Absorption Metabolism Elimination Mostly renal Some via exhalation

11 Clinical Manifestations 1. CNS Depression 2. Cardio-Pulmonary Complications 3. Renal Failure

12 Clinical Manifestations 1. CNS Depression Inebriation Cranial nerve dysfuntion 2. Cardio-Pulmonary Complications Hypotension/Tachycardia (largely due to dehydration) Myositis Non-infectious pulm infiltrates Dyspnea 3. Renal Failure Best correlates with glycolic acid levels, not crystals

13 What Labs Should Be Ordered? ETOH 0 Sal 0 APAP 0 CarboxyHbg 2% Osm 330 (Calc Osm 292) Lactate 24 PT 11.5 ph 7.18/pCO 2 8/paO 2 132/HCO 3 3

14 Laboratory Analysis Lytes Particularly, Calcium BUN, Creat Blood ph Lactate?? Urine Analysis EG Level Serum Osmolality

15 UA Ketones Oxalate Crystals Fluorescence Antifreeze Short-lived White paper, not foley

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18 Osmolality Measured calculated = Osm Gap Gap 10 mosm/kg = normal > 20 exceeds 2 standard deviations of normal Theoretically, an OG of 10 could mean an EG level as high as?

19 2 x [Na] [BUN] [Glu] [ETOH] [EG] 6.2 = Cal Osmolality Cal Osm Measured Osm = Osm Gap If Osm Gap = 10, What is [EG]? [EG] 6.2 = 10 ; [EG] = 10 x 6.2 ; [EG] = 62 mg/dl

20 Normal 0 Time

21 Elevated Lactate Lactic Acid Glycolic Acid

22 Remember stick to the basics... A, B, C s IV hydrate!!!!! Correct acidosis May need lots of bicarb Correct lytes

23 Fomepizole/4MP/Antizol Blocks ADH Level >20mg/dl, metabolic acidosis or high suspicion Dosing Load: 15mg/kg Maintenance: 10mg/kg Q12 for 4 doses then 15mg/kg Q12 HD: Q4

24 Thiamine Enhances non-toxic metabolism 100 mg IV q8 Pyridoxine (B6) Enhances non-toxic metabolism 50 mg IV q6

25 Hemodialysis Severe Acidosis (ph < 7.30) Renal failure Electrolyte imbalance High Osmolality Level > 50 mg/dl (maybe)

26 50 yo man was found confused in his garage. He has been depressed but no other history is known. He has no known medical problems and is on no medications.

27 Vitals: T 37.0C, P 88, R 20, BP 110/70 HEENT: Dry oral mucosa. Lungs: Clear. CV: Reg. GI: Soft, normal bowel sounds. Skin: Dry without lesions Neuro: Confused and requiring restraints. Moves all ext equally, good tone. +1 DTR s, CN II-XII intact.

28 Laboratory Findings ETOH 0 Sal 0 APAP 0 CarboxyHbg 2% Osm 421 (Calc Osm 292) Lactate 1.4 PT 11.5 ph 7.30/pCO 2 32/paO 2 132/HCO 3 18

29 What is the diagnosis?

30 -OH -OH -OH C-C-OH C-C-C 4. C-OH 2. C-C-C 5. HO-C-C-OH

31 Where does it come from? Antifreeze Windshield washer fluid Gas line de-freezer Copy machine fluid Sterno Solvents

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33 Clinical manifestations Least inebriating of all alcohols Retinal damage Acidosis (?why?) Huffing/inhaling can cause toxicity Pancreatitis

34 P intermembrane space 3H + 4H + 4H + 2H + CytC I II Q III IV 4H + NADH + H + succinate 4H + HCN, H 2 S, HN 3, Formic acid, & CO bind to Fe-Cu center of cyt a 3 O 2 H 2 O 2H + 3H + ADP + Pi + H + ATP + H 2 O matrix N

35 Clinical manifestations Retinal damage Snow Storm Blindness Dilated pupils Hyperemic optic disks

36 Laboratory Analysis Same as for EG... Methanol level Lipase Etc.

37 Treatment IVF Correct acidosis (Bicarbonate) Folinic acid 50 mg Fomepizole Level >20 mg/dl HD (indications can be vague) Signs of retinal damage Acidosis (ph < 7.30)

38 Folinic Acid CoFactor

39 Treatment HD (indications can be vague) Signs of retinal damage (only agreed indication) Acidosis (ph < 7.30) Keep in mind... Methanol s half-life is 54 hrs while on 4-MP

40 50 yo man was found confused in his garage. He has been depressed but no other history is known. He has no known medical problems and is on no medications.

41 Vitals: T 37.0C, P 88, R 6, BP 110/70 HEENT: Dry oral mucosa. Lungs: Snoring respirations. CV: Reg. GI: Soft, normal bowel sounds. Skin: Dry without lesions Neuro: Comatose.

42 Laboratory Findings ETOH 0 Sal 0 APAP 0 CarboxyHbg 2% Osm 332 (Calc Osm 292) Lactate 0.4 PT 11.5 ph 7.30/pCO 2 55/paO 2 132/HCO 3 23

43 What is the diagnosis?

44 -OH -OH -OH C-C-OH C-C-C 4. C-OH 2. C-C-C 5. HO-C-C-OH

45 Where does it come from?

46

47 Clinical manifestations Most inebriating of all alcohols Levels >120 mg/dl assoc w/ deep coma Gastric irritant

48 Laboratory analysis Isopropyl level Ketosis without acidosis High urinary ketones Hypoglycemia Falsely elevated creatinine

49 Treatment Supportive IVF Glucose Intubation may be necessary What if fomepizole was given?

50 Isopropanol Half life = 2-8 hours Much longer with fomepizole!!!!! Acetone Half life = 22 hours

51 On Call Medical Toxicologist 24/7 or Med Call or Poison Center