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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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What if there is the right history but no Osmolar gap?
• The osmoles get metabolized to anions!
• This means there is no parent alcohol left to inhibit!
There still may be a
toxic alcohol ingestion
with a low osmolar gap
and high anion gap!
Metabolites:
• Methanol à
formate
• Ethylene glycol à
Glycolate,
glyoxylate, oxalate
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The Toxicology Ddx of AG and Osm Gaps
Anion Gap
Osm
Gap
Ddx
High
No
Ketones
Tylenol
Salicylate
High
lactate (eg shock, status, ischemic gut)
Late toxic alcohol ingestion
High
High
Ethylene Glycol
Methanol
Ethanol
or diabetic Ketoacidosis
Propylene Glycol
ESRD with no IHD
Normal
High
Isopropyl
Alcohol
Ethanol
Severe hyperproteinemia/hyperlipidemia
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Treatment
• ABCs, IV, O2, CCM, Foley, Monitored setting
• Decontaminate
– No role (can try NG aspirate if within 60min)
• Enhanced elimination
– Acidemia allows toxic metabolites to penetrate end-organ
tissue, so give bicarb!
– Give 1-2meq/kg then set up an infusion at 150-250 cc/h
– The goal pH=7.35
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• Inhibition of alcohol dehydrogenase
– Inhibition of alcohol dehydrogenase blocks degradation of the parent
alcohol into its toxic metabolites
– Fomepizole or ethanol with:
• Folic acid 50 mg IV q6h for methanol
• Thiamine 100 mg IV and pyridoxine 50 mg IV for ethylene glycole
– Indications
• Serum methanol >6.2mmol/L or ethylene glycol >3.2mmol/L OR
• Documented recent history of ingestion of toxic amounts of methanol or ethylene glycol
and an osmolar gap>10 OR
• Suspicion of ingestion and 2 of the following:
– pH <7.3 OR Bicarb <20 OR OG>10 OR urine oxalate crystals
Treatment Continued
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Treatment Continued
• Hemodialysis
– This is the definitive therapy
– Will clear both the alcohol and their toxic metabolites
– Indications for HD - any 1 of
…
• End organ dysfunction
(eg. Coma, Seizure, Visual defects, Renal failure)
• pH≤7.15
• Persistent metabolic acidosis
• High AG metabolic acidosis
• Very high level of parent alcohol
• No antidote
83
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A quick word on the other alcohols….
• Ethanol
– Intoxication level is 4-10
– We can account for ethanol in Osmolar gap calc:
Osmolar gap=Sosm-CalcOsm
Calculated Osm=2Na+gluc+bun+(1.25xEtOH)
• Isopropyl alcohol
– Treatment is just supportive
84
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Salicylate Sources
OTC
Rx
Topi cal
Herbal
Alka
-seltzer (ASA +
sodium bicarb)
Aggrenox
(
ASA+dipyridamole)
Acne cleansers
Red Oil Chinese
Anacin (ASA + caffeine)
ASAcol
(mesalamine /
5
-ASA = aminosalycylic
acid)*
Arthritis topicals
Red / White flower oil
Aspirin (ASA)
Ecotrin (also ASA)
Fiorinal
(ASA+
butalbital/caffeine)
Oil of wintergreen
(methyl salicylate)
Koong
Yick Hung Fa Oil
Excedrin (ASA, caffeine,
acetaminophen)
Wart removers
Minyak
Cap Kapak
Pepto
-bismol (bismuth
subsalicylate)
Dandruff Shampoos
Kaopectate
(subsalicylate)
Entrophen
(ASA)
BONUS
Read on own
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• Get neuronal energy depletion as salicylates uncouple
neuronal and glial oxidative phosphorylation
• Get a discordance between serum and CSF glucose
concentrations
– Despite normal serum glucose concentrations, CSF glucose
concentrations are low in 33%
• May also get cerebral edema resulting in a coma +/- seizures
A special word on the brain and Salicylates
BONUS
Read on own
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87
Salicylate Toxicity
Early Findings
(1-2h post-ingestion)
Late Findings
-
Tinnitus
-
Nausea, vomiting
-
Hyperventilation
-
Fever
-
Coma/seizures
-
Non-cardiogenic pulmonary edema
-
Arrhythmia
-
Thrombocytopenia
-
AKI
Good Practice Oral
Exam Scenario!
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• Salicylate level
– Toxi ci ty w it h serum levels greater than 2.9-3.6mmol/L
– Order levels q 2-4 hours
• ABG/VBG
– Respiratory alkalosis à direct stimulation of the resp centre
– Anion gap metabolic acidosis à uncoupling of oxidative phosphorylation
– Common to see a mixed acid-base disturbance with 2 primary problems
– If concurrent respiratory acidosis, consider:
– Acute lung injury
– CNS depression
– Mixed overdose
Labs
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