To start of the new season, here is a Case suggested by David Williams.
A 30 year old woman with a history of suicide attempts, admitted to
Casualty in a semi-comatose state. Serum results were:
Sodium: 140 mmol/L
Potassium: 2.4 mmol/L (3.6 - 5.3)
Bicarbonate: 7 mmol/L (22 - 31)
Urea: 3.6 mmol/L
Creatinine: 116 umol/L
Glucose: 8.7 mmol/L
Lactate: 5.1 mmol/L (<1.8)
Osmolality: 407 mOsm/kg (285 - 295)
This Case attracted 40 participants, who produced a very clear concensus.
12 thought it necessary to make urgent contact with the Clinicians to
discuss the possibilities and/or to suggest treatment.[1.8]
16 pointed out the large osmolal gap; [1.8]
2 thought that this may be partly or wholly artefactual, and suggested
checking with a fresh sample; [0.5]
8 pointed out the severe metabolic acidosis. [1.5]
4 suggested methanol poisoning; [1.5]
5 suggested ethylene glycol poisoning; [1.8]
25 suggested methanol and/or ethylene glycol poisoning. [2.0]
2 also suggested that paraldehyde might be responsible.[0.3]
9 suggested immediate treatment with an ethanol infusion; [1.5]
4 would ring a Poisons Unit to ask for advice. [1.3]
12 would ask for a sample for blood gases; [1.3]
6 would measure chloride to calculate an anion gap; [0.8]
1 thought that chloride probably wasn't worth measuring. [0.5]
7 thought the hypokalaemia was surprising, and queried other toxicological
causes; [1.3]
2 of these specifically mentioned theophylline, [-0.3]
2 mentioned laxative abuse, [-0.3]
7 would ask for a urine sample for a toxicology screen. [1.3]
6 would measure/ arrange to have measured methanol and ethylene glycol;
[2.0]
6 would look for oxalate crystals in urine; [1.3]
11 would measure calcium; [2.0]
4 would measure amylase; [0.8]
3 would measure LFTs [1.3]
1 would check a dipstick glucose. [0.8]
This was a case of ethylene glycol poisoning, who did not develop renal
problems and who survived. Here at the Royal Berkshire Hospital, we see 1 -
2 similar cases a year. We don't have a local method for ethylene glycol,
but have rapidly managed to find the characteristic calcium oxalate
monohydrate crystals in random urine samples. Lorne Massey of the
University of Saskatchewan has sent us details of a very similar Case she
saw in March, [Prestone Antifreeze] in which the osmolality was an amazing
674 mOsm/kg, the measured ethylene glycol being 240 mmol/L. This patient
was treated with haemodialysis, made a complete recovery, and was
discharged to the psychiatrists three days later.
Best wishes
Gordon Challand
Ping Li
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