Comatose patient case discussion
10 likes4,468 views
This document discusses the case of a 34-year-old male found unconscious after ingesting radiator fluid. The patient presents with coma, hypothermia, respiratory distress, renal failure, and a high anion gap metabolic acidosis. Laboratory findings include an elevated osmolal gap and normal arterial blood gases. The registrar analyzes the patient's condition and laboratory results, determining the likely diagnosis is ethylene glycol poisoning presenting late with complications including aspiration pneumonia and renal failure. Immediate management should include interventions for hypothermia, renal replacement therapy, and antidote therapy with fomipizole or ethanol infusion.
![Any thing else you would ask for?
ABGs:
pH 7.77, PaCO2 35.5, PaO2 57, HCO3 50.6
Check Internal data for consistency
[H+]= 24 x PaCO2/HCO3
24 x 35.5/50.6= 16.8
[H+]=7.8-pH x 100
7.8-7.77x 100= 3](https://image.slidesharecdn.com/comatosepatientcasediscussion-140403174644-phpapp01/85/Comatose-patient-case-discussion-13-320.jpg)
![Remaining steps of ABGs analysis
• Is the respiratory compensation adequate?
• Winter formula
• Exp pCO2 = [1.5(measured HCO3
-)]+8± 2
• Exp pCO2 = [1.5(3.7)]+8±2= 13.5 ±2
• So what is this?
• Respiratory element !!!
• Why?
• Low GCS and Chest problem infective process](https://image.slidesharecdn.com/comatosepatientcasediscussion-140403174644-phpapp01/85/Comatose-patient-case-discussion-23-320.jpg)
Comatose patient case discussion
- 1. Case Discussion Muhammad Asim Rana BSc, MBBS, MRCP, MRCPS, FCCP, EDIC, SF-CCM Department of Critical Care Medicine King Saud Medical City Comatose Patient
- 2. Clinical Summary • You are the on call ICU Registrar and are covering the night shift. • You have almost finished your energy reserves at around 4 am, after finishing wards round and just came back to the ICU doctors room and thrown your self in chair when the bleep rings Why does Asim like such worst scenarios always?
- 3. History • 34 years old male Indian patient • Car mechanic by profession • Brought to A & E by Red Crescent • No past medical history • No attendant available. • Patient was found unconscious in the workshop and they found empty bottle of radiator fluid near him. • ER called MSP and he has called you as patient is unconscious
- 4. Dilemma continues • ER and MSP are looking at you to take him to ICU because of low conscious level. • What you are supposed to do? 1. Fight with ER & MSP that why they have not assessed the case before calling you 2. Read the file…… 3. Call your senior 4. Start examining the patient Very Bad Senior Again!!!
- 5. Causes of COMA Structural OR Surgical •DIFFUSE DAMAGE TO BOTH HEMISPHERES •VASCULAR DAMAGE • INCREASED ICP Metabolic OR Medical Diffuse insult to both cerebral hemispheres by toxins, either from within or from outside
- 6. Alcohol Epilepsy/Exposure Insulin(Diabetic) Overdose/Oxygenlow Uremia(kidneyfailure) Trauma/HeadInjury InfectionorIatrogenic Psychosisorpoisoning Strokes A E I O U T I P S Causes of COMA
- 7. Clinical Summary • You see him wearing a single T-Shirt and Trousers with very cold weather out side, otherwise GPE is unremarkable. You are told pt has been having diarrhea • Vitals: – Temp 32:C, BP 130/85, HR 129/min regular, SpO2 87% on 10 liters per min NRM • CNS: – GCS: E1M5V2 – No lateralization – No signs of meningeal irritation – Pupils bilaterally constricted equal and reactive – Bilateral up going planters
- 8. Clinical Summary • Cardiovasular Exam: – Unremarkable except for tachycardia, auscultation normal • Abdomen: – Unremarkable, the patient vomited while you were examining the abdomen-coffee ground • Respiration: – Decreased Rt sided movements with decreased air entry on Rt lower zone especially in Rt axillary area with coarse crepts and broncheal breathing
- 9. Chest X-Ray
- 10. Laboratory Investigations • CBC.. Hb% 14, WBCs 12, Platelets 230 • Na 140. K 6.6, Cl 109, Blood Glucose 200mg% • BUN 28, Creatinine 344 • CK 8700, ALT 77, AST 92, ALP 150, Billir 17 • Amylase 23, Lipase 12 • Hepatitis viral markers negative • HIV negative
- 11. Whatyouwilldonow? • Think of the steps you have to take as an Intensivists: • Need to know Diagnosis or ??? • Intubation and securing the airway? • Reviewed the labs… What next? • Looked at CXR.. What is this? • What next? • What antibiotics? • What we are missing? • Hypothermia needs attention or NO?
- 12. What else do you need? Ct Brain Normal CSF analysis Proteins 34, LDH 12, Sugar 67mg% (RBS 200mg%), Cell count 3, all lymphocytes. Latex negative
- 13. Any thing else you would ask for? ABGs: pH 7.77, PaCO2 35.5, PaO2 57, HCO3 50.6 Check Internal data for consistency [H+]= 24 x PaCO2/HCO3 24 x 35.5/50.6= 16.8 [H+]=7.8-pH x 100 7.8-7.77x 100= 3
- 14. Venous Blood Gas Repeated • pH 6.878, PaCO2 20, PaO2 27.2, HCO3 4 • What is the impression now? • How do we analyze the Blood Gas results? • The six steps approach • Although there is much to discuss about reading blood gases…
- 15. Step-wise Approach 1. Acedemia or Alkalemia 2. Metabolic or Respiratory 3. For metabolic is it anion gap or non anion gap. 4. For anion gap acidosis,is it associated with other disturbances. 5. What is the respiratory compensation for the metabolic disturbances. 6. For respiratory disturbances is it acute or chronic.
- 16. Step-wise Approach • Step1: • Acidemia or Alkalemia? • Acidemia • Step2: • Metabolic or Respiratory? • Metabolic • Step3: • Is there anion gap or no? • 140-109+4=27 • Yes high anion gap metabolic acidemia
- 17. High Anion Gap Metabolic Acidemia • M • U • D • P • I • L • E • S
- 18. High Anion Gap Metabolic Acidemia • Methanol • Uremia • DKA • Paraldehyde • Ischemia, Iron, INH, Isopropyl alcohol • Lactic acidosis • Ethylene glycol • Salicylates
- 19. Back to Brain Exercise • What could be the cause in our patient? • Yes, He might be a case alcohol ingestion!! • Which Alcohol? • Methanol, Ethanol, Ethylene glycol, Isopropyl Alcohol • How will you proceed further? • Check Serum Osmolality, Urine for? • Why & which one,.. Calculated or measured?
- 20. Continue The Thinking Process • Osmolal Gap = Measured osmolarity - Calculated osmolarity Normal 0 - 10. Abnormal > 10. • Calculated osmolarity = 2 x (Na+) + BUN/2.8 + Glucose/18
- 21. Move your Brain Cells Na+ = 140, Glucose = 200, BUN = 28 Measured serum osmolality = 310 • Osmolal gap = Measured OSM - Calculated OSM: = 310 - (2x140 + 200/18 + 28/2.8) = 310 - (280 + 11 + 10) = 310 - 301 = 9 Now What There is NO Osmolal Gap?
- 22. Remember!!! • All alcohols are osmotically active • Methanol and Ethanol are characterized by – High Anion Gap Acidosis – Osmolal gap • Only methanol and ethanol are metabolized to acids • Isopropyl Alcohol is metabolized to acetone. • Ethylene glycol may be metabolized completely to toxic metabolized not active osmotically…. Normal Osmolal gap.. • Late presentation!!!!
- 23. Remaining steps of ABGs analysis • Is the respiratory compensation adequate? • Winter formula • Exp pCO2 = [1.5(measured HCO3 -)]+8± 2 • Exp pCO2 = [1.5(3.7)]+8±2= 13.5 ±2 • So what is this? • Respiratory element !!! • Why? • Low GCS and Chest problem infective process
- 24. Remaining steps of ABGs analysis • Are there any other metabolic disturbances? • Corrected HCO3 - = Measured HCO3 - + Delta gap • Delta Gap? • Calculated Anion Gap – Normal Anion Gap • Corrected HCO3= ( AG-12) +Measured HCO3 • 24=(AG-12)+Measured HCO3 • 24=(27-12)+Measured HCO3 • 24=(15)+4= 19 • This stays less than 24… So what does it mean? There is additional non anion gap metabolic acidosis What could be the reason?
- 25. Normal Anion Gap Acidosis (Hypokalemia) • Diarrhea • Ureteral diversion • Renal tubular acidosis – Proximal – Distal • Mineralcorticoid deficiency • Carbonic anydrase inhibitor – Acetazolamide – Mefenamic acid • Post hypocapneic state
- 26. Normal Anion Gap Acidosis (Hyperkalemia) • Early renal failure • Renal disease –SLE interstitial nephritis –Amyloidosis –Hydronephrosis –Sickle cell nephropathy • Acidifying agents –Ammonium chloride –Calcium chloride –Arginine • Sulfur toxicity
- 27. Summary of Assessment • Case of alcohol ingestion(Ethylene Glycol) with complications masking the clinical picture • Late presentation • Aspiration pneumonia • Early Renal Failure – Rhabdomyolysis – Ethylene Glycol • Hypothermia
- 28. Management • Which of the following interventions is most likely to benefit this patient? 1. IV fluids (Crystalloids) 2. Ethanol infusion 3. Fomipizole 4. Thiamine 5. Haemodialysis
- 29. Hope we conveyed the message Thank you for your patience