32 F – presents with AMS. EMS reports neighbors smelled gas and called 911. They found patient unresponsive (? Sleeping) initially in the apt.  Patient doesn’t remember these events  but does recall that she is staying at a friends and had a few drinks earlier in the night mixed with 1 Xanax. nd isn’t sure how the gas got turned on. Vitals stable. Physical exam aside from being confused about events unremarkable.

Labs: alcohol (271), ASA (wnl), Tylenol (wnl)

Initial VBG: pH 7.34, PCO2 55, PO2 40 lactate 1.5

Carboxyhemoglobin 0.9

EKG- NSR 79, no STT changes. Incomplete RBBB. Flattening T waves laterally

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Filed under: tox by tali
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78 yo f presents with generalized weakness. Patient denies any complaints per se and was brought in by family member after patient could not answer her door due to her weakness. Vital signs were stable. Physical exam was unremarkable and she had not other ROS complaints.

Initial venous blood gas revealed pH of 7.21, pco2 40, lactate 2.1 and glucose of 20.

Initial ER venous revealed Na of 140, K 5.1, Cl 109, CO2 23, Bun 19, Cr 1.1 and glu 20.

Patient has a non-anion gap acidosis. Helpful mnemonic for differential in this category is HARDUP.

• Hyperalimentation
• Acetazolamide or other carbonic anhydrase inhibitors
• Renal Tubular Acidosis
• Diarrhea
• Ureteroenteric fistula
• Pancreaticoduodenal fistula

Of these, RTA is most likely given her history and physical. Which RTA however?

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Filed under: Pearls by keiko
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23 year old male with HIV presents with 1 week of fever, cough with yellow sputum, malaise presents with worsening of symptoms. Patient has vital signs of T103, P110, BP135/89, sat 90% on RA. Physical exam reveals coarse rhonchi bilaterally. His initial pa02 is 78 mm Hg. Below is the chest x-ray.

What is the next initial management after starting IV TMP-SMX?

A. Corticosteroids

B. Intubate

C. Continue supportive care

D. Start antiretroviral therapy

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Filed under: Pearls by keiko
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It has been a long, eventful week in the wake of the tragedies in Boston and to honor those who were affected by the attacks, I would like those who are able, to have a moment of silence at 2:50 PM. 

To those further interested, below is the link to ‘The One Fund Boston’ to help those most affected by this tragedy. 

The One Fund Boston 2013

Please see below for today’s pearl.

Filed under: Pearls by keiko
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Good morning! Please see above for a response to last week’s tragedy.

44 yo female presenting with nausea, vomiting and abdominal pain. Patient is a chronic alcoholic with no other drug use admitted. Patient is tachycardic to 116 and hypotensive 90/68. She is alert and oriented x 3 but actively vomiting clear non-bilious and non-bloody vomit. She is tender in the epigastric and ruq. No tremors, jaundice or significant findings on exam. She has a Na 139, K 4.5, Cl 91, Co2 5, Bun 16, Cr 1.1. Her pH and lacate is 7.08 and 8.5, respectively, her urine dipstick contains ketones. There is no osmolality gap. What is your next best step in management after starting normal saline fluids?

A. CT scan of the abdomen

B. Thiamine and glucose infusion

C. Phosphate level

D. Abdominal x-ray

In this patient with a gap acidosis most likely relating to her chronic use of alcohol, the typical treatment of fluids and most importantly fluids with glucose and thiamine to help the nutrition depleted patient to improve their acid-base imbalance.

Alcoholic ketoacidosis usually develops in chronic alcoholics given their pan-nutritional deficiency status, causing the body to make ketones from the fasting state of alcohol only intake combined with low to none normal dietary food sources.

Patients, however, who develop marked hypophosphatemia are in significant risk for life-threatening sequelae including myocardial dysfunction or encephalopathy. Therefore, it is very important to ascertain the phosphate levels in such individuals to replet such a deficiency. Levels in a patient can be normal, but once treatment starts the insulin the body starts producing can drive extracellular phosphate intracellularly causing a drop in the level.

Although this occurs 12-36 hours after treatment, depending on where the level of phosphate is or how long the patient has been in the emergency department for, it is important to keep that in mind in the treatment of AKA.

Thanks to Dr. Hansen for his morning report.

Filed under: Pearls by keiko
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