“Carbon Monoxide Poisoning” … Case Conclusion February 5, 2011
Posted by ebmedicine in Toxicologic Emergencies.Tags: carbon monoxide poisoning, treating carbon monoxide poisoning
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The Conclusion Is…
The local Poison Control Center was promptly contacted and the controversies, risks, and benefits of HBO treatment were discussed. The local HBO center was contacted and because of its close proximity and because the patient had evidence of end-organ damage, the decision was made to transfer the patient for treatment. She received an aspirin for her ECG changes and was transferred with ongoing NBO therapy. The HBO treatment was provided without complication. The patient was admitted to the medical service, after which she underwent 2 additional “dives” during her hospitalization. Her 6-hour troponin I level peaked at 2.1 mg/L, and an ECG obtained at that time had returned to her baseline. Subsequent cardiac biomarkers were obtained 12 hours after presentation and were normal. She remained hemodynamically stable and free of symptoms during her hospitalization. After undergoing stress echocardiography testing on hospital day 2, which did not reveal evidence of reversible myocardial ischemia, she was discharged on hospital day 3. At a 6-week clinic follow-up appointment, she denied any symptoms and had a normal examination. However, she said she had sold her apartment and moved in with her son’s family.
Congratulations to Dr. Borek, Dr. Dar, and Dr. Waters — this week’s winners of Emergency Medicine Practice’s “Diagnosis And Management Of Carbon Monoxide Poisoning In The Emergency Department!” For an evidence-based review of the epidemiology, pathophysiology, diagnosis, and management of CO poisoning in both the general population and special populations, read the February 2011 issue of Emergency Medicine Practice, “Diagnosis And Management Of Carbon Monoxide Poisoning In The Emergency Department.”
Carbon Monoxide Poisoning… January 24, 2011
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An 89-year-old female is found by her family, lying unconscious on her kitchen floor, after they had been unable to reach her by phone for several hours. EMS is activated and when the paramedics arrive, they note that the gas oven is on, and there is thin, gray smoke coming from around the door. The house gas supply is turned off, windows are opened, and the family and the patient are immediately evacuated from the home. En route to the hospital, the patient is placed on high-flow oxygen at 15 liters per minute by non-rebreather mask. Her bedside glucose determination is 229 mg/dL. Vital signs are within normal limits during transport. She opens her eyes to sternal rub and makes spontaneous movements of all extremities. Upon arrival to the ED, the patient becomes more alert and is able to respond to your questions. She tells you that she remembers putting a tray of calzones into the oven, after which she has no recall of the day’s events. She has a past medical history of “well-controlled” hypertension, hyperlipidemia, and non-insulin-dependent diabetes. Her medications include hydrochlorothiazide 25 mg daily, lisinopril 10 mg daily, simvastatin 20 mg daily, and metformin 1000 mg twice daily. On physical examination, weight is 65 kg, blood pressure is 97/50 mm Hg, heart rate is 113 beats per minute, respiratory rate is 22 breaths per minute, temperature is 37.1°C (98.8°F), and oxygen saturation is 99% on 15 liters per minute via non-rebreather mask. She appears her stated age. Cardiopulmonary examination is remarkable only for tachycardia. Her abdomen is soft and non-tender with normal bowel sounds. Her skin is warm and dry, and there is no peripheral edema. Her cranial nerves are intact, with briskly reactive, symmetric pupils. Motor and sensory examination is non-focal, and cerebellar testing is notable only for an intention tremor on finger-nose-finger test. Gait is normal and speech is fluent and without errors. Laboratory testing shows a hemoglobin of 10.3 g/dL and a leukocyte count of 11.7 x109/L. Electrolyte results fall within the normal range, and her serum creatinine is 1.7 mg/dL. Qualitative CK-MB and troponin I tests are positive, and the sample has been sent to the STAT lab for quantitative testing. Serum carboxyhemoglobin level is 15% with normal serum pH on an arterial blood gas. An ECG reveals deep, down-sloping inferior and lateral ST-segment depressions which were not present on a routine cardiogram 1 month prior. You have many questions about this patient’s care.
What symptoms and physical signs need to be addressed and treated? What additional diagnostic testing should be performed? What treatment regimen is appropriate, and what should be avoided? What are the risks or delayed complications from her illness? Are there special considerations for this or other patient populations?
(Enter to win the latest issue of Emergency Medicine Practice, including CME, by submitting your answer. To do so, simply enter your response in the comments box. The deadline to enter is January 6th.)
“Toxic Alcohols” … Case Conclusion November 3, 2010
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The Diagnosis Is…
An IV line was placed, fomepizole was administered in a dose of 15mg/kg, and the patient was placed on fall precautions. Lab work revealed the following: an anion gap of 25, an arterial pH of 7.25, an osmolar gap of 30, and a BUN:creatinine ratio of 13:0.6. Her ethanol level was nondetectable. A discussion with the local poison control center revealed that most windshield-washer fluids contain methanol and some may contain ethylene glycol. Nephrology was consulted regarding the need for hemodialysis, and she was admitted to the ICU, at which time results of the methanol and ethylene glycol tests were still pending. A methanol concentration of 70 mg/dL was found 24 hours after admission, warranting fomepizole therapy until her methanol level was less than 20 mg/dL. Hemodialysis was initiated upon admission to the ICU and was discontinued once her acidemia resolved. Three days later, the patient was transferred to psychiatry, neurologically intact.
Congratulations to Dr. Bill H, Dr. Patel, Dr. Osman, Dr. Sana, and Dr. Simsek — this week’s winners of Emergency Medicine Practice’s “Toxic Alcohols: Not Always A Clear-Cut Diagnosis!” For a review of diagnostic approach to toxic alcohol poisoning, as well as the pathophysiology, management, and treatment specific to each of the toxic alcohols, read the November 2010 issue of Emergency Medicine Practice, “Toxic Alcohols: Not Always A Clear-Cut Diagnosis.”
Toxic Alcohols… October 26, 2010
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A 45-year-old woman with a history of depression is brought to the hospital by her family 2 to 3 hours after an intentional ingestion of windshield-washer fluid. Her family wants to know if she is going to be okay and when she can go home. Her initial triage vital signs include a heart rate of 88 beats per minute, a respiratory rate of 14 breaths per minute, and pulse oximetry of 100% on room air. Upon examination, she appears lethargic but neurologically intact and is ambulating without difficulty. As you order a serum osmolality, electrolytes, and serum ethanol, methanol, and ethylene glycol concentrations, you realize that you haven’t taken care of a patient with a toxic alcohol ingestion in years. You wonder if you should begin treatment right away, whether hemodialysis is indicated, and how to interpret the labs once they are reported.
How do you proceed…and what’s your diagnosis?
(Enter to win the latest issue of Emergency Medicine Practice, including CME, by submitting your answer(s). To do so, simply enter your response in the comments box. The deadline to enter is November 6th.)
“APAP Overdose” … Case Conclusion September 7, 2010
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The Diagnosis Is…
The young woman who presented after the acute ingestion would have been a perfect candidate for AC therapy, since she presented within an hour of her acute ingestion. However, she was not given ipecac or AC because she was already vomiting, and you wanted to avoid possible aspiration. You checked her APAP level 4 hours after the ingestion and found it to be slightly above the toxic range. Her AST concentration was also slightly elevated. The rest of her laboratories and the toxicology screen were unremarkable, so you started her on the NAC regimen and admitted her to the general medical ward. She completed the full course of treatment and was observed on the general medicine service over the next few days. Her elevated AST returned to baseline and her symptoms resolved gradually. Before she was discharged, she underwent a psychiatric evaluation and was deemed safe to return home.
Congratulations to Dr. Bolden, Dr. Foster, Dr. Gupta, Dr. Patrick, and Dr. Rossi — this week’s winners of Emergency Medicine Practice’s “An Evidence-Based Approach To Acetaminophen (Paracetamol, APAP) Overdose”! For an evidence-based review of most commonly encountered postpartum emergencies (headache, LPPE, hypertension, and cardiomyopathy), read the September 2010 issue of Emergency Medicine Practice, “An Evidence-Based Approach To Acetaminophen (Paracetamol, APAP) Overdose.”
APAP Overdose… August 26, 2010
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You receive an EMS alert about a young female patient en route to the ED after an apparent suicide attempt. She was found by her apartment roommates, vomiting, with an empty bottle of acetaminophen (APAP) beside her. The roommate states that she last saw the patient normal the night before. The patient is complaining of diffuse abdominal pain but is reluctant to tell the paramedics how many pills she had taken.
Should you give this patient charcoal? Should you give her a dose of NAC while waiting for the APAP level to come back from the laboratory? Is there a difference between oral and IV NAC? How do you make a management decision if you don’t know when the ingestion took place?
(Enter to win the latest issue of Emergency Medicine Practice, including CME, by submitting your answer(s). To do so, simply enter your response in the comments box. The deadline to enter is September 6th. [Note: A valid email address is required to be eligible to win. Your email will only be used to contact you in the event you win and will not be publicly displayed.”])
