Steph, Aaron & Ben. Patient Presentation Brought in by co-workers due to being found disoriented &...
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- Slide 1
- Steph, Aaron & Ben
- Slide 2
- Patient Presentation Brought in by co-workers due to being
found disoriented & confused 60-90 min ago. He is now alert
& oriented x3 but complains of dizziness, headache and nausea.
Sweet odor on his breath. Pt is agitated and unable to give an
adequate history. Pt monitored in ER due to symptoms not subsiding.
5 hours later pt develops intense upper abdominal pain, nausea,
vomiting & diarrhea.
- Slide 3
- Social Hx Tobacco: Smokes 1 ppd Alcohol: Social drinker on
weekends Work: Large engine repair facility for 6 years.
Medications: Tylenol (prn)
- Slide 4
- Physical Exam (Pertinent +s) Vitals: 110/80, HR: 146 bpm, RR:
30 bre/min, Temp: 101 F Height: 510, Wt: 205 BMI: 29.5 Heart: Rough
systolic sound Abdomen: Tender upper abdomen Neurological:
Lethargic, Hyporeflexive
- Slide 5
- Class DDx
- Slide 6
- Our DDx Cholecystitis Alcoholic Ketoacidosis Diabetes Mellitus
Acute Hepatitis Ethylene glycol poisoning Other Occupational
Toxicity
- Slide 7
- Acute Hepatitis Acute viral infection causing hepatocellular
damage. Cause: Depends on the strain. A & E: Fecal Oral,
foreign travel B, C & D: Mucosal transfer Symptoms: Range from
none fulminant hepatic failure. Flu like Nausea, vomiting, diarrhea
Jaundice in 1/3 of pts. Dx: Symptoms, Liver panel & Hepatitis
Serology (gold standard!)
- Slide 8
- Liver Panel Albumen: 4.7 g/dL (3.5 4.8 g/dL) ALP: 44.8 U/L (38
126 U/L) Amylase: 104.4 U/L (30 110 U/L) Ca ++ : 9.2 mg/dL(8.9 10.4
mg/dL) Direct Bili: 0.1 mg/dL(< 0.3 mg/dL) GGT: 46 U/L(8 78 U/L)
LDH: 80.4 U/L(56 194 U/L) Phosphate: 3.3 mg/dL(2.5 4.5 mg/dL) Tot
prt: 6.2 g/dL(6.0 8.2 g/dL) Tot Bili: 0.4 mg/dL(0.2 1.3 mg/dL) ALT:
98 U/L (7 56 U/L) AST: 80 U/L (5 35 U/L) BUN: 6.5 mg/dL(7 21 mg/dL)
Hepatitis Serology: All Negative
- Slide 9
- Symptoms that correlate Nausea, vomiting Elevated ALT & AST
(hepatocellular damage) Symptoms that do not correlate No jaundice
& normal Bilirubin levels Sweet odor on his breath Negative
hepatitis serology! Acute Hepatitis cont.
- Slide 10
- Cholecystitis Inflammation of the gall bladder. Causes: Most
commonly Cholelithiasis leading to bile stasis and secondary
infection by gut organism. Symptoms Upper Rt. Quadrant abdominal
pain Low grade fever Nausea & Vomiting Dx: By Symptoms &
elevated WBCs What next? Check CBC
- Slide 11
- CBC Result Auto Diff %: Normal RBC: 5.1 x 10 12 /L (4.3 6.2 x
10 12 /L) Hematocrit: 47.4% (40 52%) Hemoglobin: 16.0 g/dL (13.2
16.2 g/dL) WBC: 9.0 x 10 9 /L (4.1 10.9 x 10 9 /L) MCV: 78.0 fL (78
102 fL) Platelets: 190.4 x 10 9 /L (140 150 x 10 9 /L) RDW: 12.9%
(11.5 14.5%) WBC: 9.0 x 10 9 /L (4.1 10.9 x 10 9 /L)
- Slide 12
- Symptoms that correlate Tender upper abdomen Fever Nausea &
Vomiting Symptoms that do not correlate Sweet odor on his breath
Normal WBC count Cholecystitis cont.
- Slide 13
- Diabetes Mellitus Fasting plasma glucose 126 mg/Dl *Casual
plasma glucose 200 mg/Dl ( if accompanied by symptoms)
- Slide 14
- DM Symptoms Polyuria Polydipsia Blurred vision Diabetic
ketoacidosis Symptoms of hypoglycemia: *Personality change
*Cognitive impairment *Loss of consciousness *Seizure *Coma
*Irreversible brain injury
- Slide 15
- DM cont. Labs: Casual Glucose: 104.8 mg/dL(65 110 mg/dL)
Fasting Glucose: 90.5 mg/dL (60 110 mg/dL) Hemoglobin-A1c: 6.1% (6
8%) Symptoms that correlate Loss of consciousness & delirium
Sweet smelling breath Findings that dont correlate Normal
casual/fasting glucose
- Slide 16
- Ethylene Glycol Poisoning Antifreeze Hydraulic Brake Fluid
Industrial Solvents Paints and Lacquers Cosmetics Viscous Colorless
Odorless Slightly Sweet Tasting
- Slide 17
- Pharmacology and Absorption Rapid absorption Peak blood levels
within 1-4 hours after ingestion Nonvolatile so inhalation unlikely
Toxic and lethal doses are 0.2-1.4 mL/kg ~25% of it is excreted
unchanged and the rest is hepatically oxidized via aldehyde
dehydrogenase and other oxidative enzymes.
- Slide 18
- Clinical Features 30 minutes to 12 hours after ingestion
Possible Symptoms CNS depression Slurred speech Nystagmus Ataxia
Vomiting Decreased visual acuity Papilledema Decreased pupillary
reflexes Hallucinations Convulsions Coma Sweet odor on breath Case
Headache Dizziness Nausea Sweet Odor on breath Social Drinker
Difficulty concentrating Slightly ataxic Intense upper abdominal
pain Diarrhea Drowsy Disoriented BP: 110/80 HR: 146 Resp: 30 Temp:
101
- Slide 19
- Clinical Features 12-24 hours after ingestion Possible Symptoms
Mild hypertension Tachycardia Tachypnea due to metabolic acidosis
Pulmonary edema Case Headache Dizziness Nausea Sweet Odor on breath
Social Drinker Difficulty concentrating Slightly ataxic Intense
upper abdominal pain Diarrhea Drowsy Disoriented BP: 110/80 HR: 146
Resp: 30 Temp: 101
- Slide 20
- Useful Laboratory Tests Serum electrolytes Calcium BUN
Creatinine Serum glucose Serum osmolality Arterial blood gasses
Ethylene glycol level EKG Urinalysis for crystaluria (~50% of
cases) Leukocytosis may be seen.
- Slide 21
- Urinalysis Overall:Normal color w/o crystals Glucose: Negative
Ketones: Negative Leuko Esterase: Negative pH: 6.1 (5-7) Protein:
2+ mg/dL (negative trace) Sp Grav: 1.007 (1.002 1.03) Urobilinogen:
0.85 (0.2 1.0)
- Slide 22
- Classic Patients who ingest ethylene glycol appear intoxicated
without the odor of ethanol and have an anion gap metabolic
acidosis and calcium oxalate crystalluria. This is without evidence
of alcoholic ketoacidosis or diabetic ketoacidosis.
- Slide 23
- Alcohol & Alcohol Withdrawal Alcohol withdrawal usually
develops 6-24 hours after the reduction of ethanol and lasts from
2-7 days. Alcohol ketoacidosis is a result of starvation with
glycogen depletion, a raised NADH to NAD ratio related to the
metabolism of ethanol, and volume depletion resulting in
ketogenesis in the liver as an alternative source of energy.
- Slide 24
- Alcohol Withdrawal Symptoms Possible Symptoms Headache
Confusion Fever/Diaphoresis Seizures Irritability Insomnia Tremor
Weight loss Palpitations Frequent s Stools Delirium Case Headache
Dizziness Nausea Sweet Odor on breath Social Drinker Difficulty
concentrating Slightly ataxic Intense upper abdominal pain Diarrhea
Drowsy Disoriented BP: 110/80 HR: 146 Resp: 30 Temp: 101
- Slide 25
- Alcohol Ketoacidosis Symptoms Possible Symptoms Nausea/Vomiting
Abdominal pain Tremulousness Dizziness Muscle pain Fever Diarrhea
Syncope Seizure The fruity odor of ketones may be present on breath
Impaired Mental Status Tachycardia Tachypnea Hypotension Case
Headache Dizziness Nausea Sweet Odor on breath Social Drinker
Difficulty concentrating Slightly ataxic Intense upper abdominal
pain Diarrhea Drowsy Disoriented BP: 110/80 HR: 146 Resp: 30 Temp:
101
- Slide 26
- Arterial Blood Gasses O 2 Sat: 95% HCO 3 : 25.3 mEq/L (22 26
mEq/L) pCO 2 : 15 mmHg (35 45 mmHg) pH: 7.3 (7.34 7.44) pO 2 : 100
mmHg (75 100 mmHg) Serum CO 2 : 30.5 meq/L (20-29 meq/L) Cl - :
105.3 meq/L (80-120 meq/L) HCO 3 : 20 meq/L (20-26 meq/L) K + : 4.1
meq/L (3.6-5.0 meq/L) Na + : 145 meq/L (137-145 meq/L) Blood
Electrolytes
- Slide 27
- Occupational Toxicity Occupational Hazard:
1,1,2,2-tetrachloroethane Use: industrial solvent used to degrease
metals Physical Properties: synthetic, colorless, dense liquid that
does not burn easily, sweet odor similar to chloroform. Exposure:
Inhalation, ingestion, direct skin contact
- Slide 28
- Occupational Toxicity Expected Symptoms Inhalation: drowsiness,
dizziness, nausea, and vomiting. Breathing high levels for a long
time can cause liver damage. Liver damage/injury, reduced liver
function, increased risk for hepatocellular tumor, and
steatosis
- Slide 29
- Occupational Toxicity Symptoms that Correlate: Delirium,
headache, dizziness, nausea, sweet odor on breath Labs: Liver
Panel: elevated AST and ALT -everything else normal What next?
Liver Biopsy
- Slide 30
- Overall: steatosis and central lobular necrosis
- Slide 31
- 1,1,2,2 tetrachloroethane extensively metabolized by liver and
excreted chiefly as metabolites in the urine and breath Metabolized
via cytochrome P450 pathway Metabolism produces reactive radicals
and acid chloride intermediates Responsible for hepatocellular
damage
- Slide 32
- Suggested Metabolic Pathways of 1,1,2,2-Tetrachloroethane
http://www.atsdr.cdc.gov/toxprofiles/tp93-c3.pdf
- Slide 33
- Five hours later The patient becomes acutely ill. He develops
intense upper abdominal pain, nausea, vomiting and diarrhea. He
becomes drowsy and disoriented. Probable diagnosis: Liver failure
with hepatic encephalopathy
- Slide 34
- Hepatic Encephalopathy Definition: A state of disordered
central nervous system function resulting from failure of the liver
to detoxify noxious agents of gut origin because of hepatocellular
dysfunction and portosystemic shunting. Symptoms Drowsiness,
stupor, delerium asterixis, progressing to coma Treatment
Lactulose: results in colonic acidification and elimination of
nitrogenous products in the gut Promotes 2-3 soft stools per day
Neomycin Sulfate: controls ammonia-producing intestinal flora 0.51
g PO q6 or 12h for 7 day Oral protein intake limited Labs: Ammonia:
12.7 mol/L (11 35 mol/L)
- Slide 35
- Treatment of Occupational Toxicity Remove the chemical Wear
protective mask and clothing Do not use solvent (not commonly used
in US due to high risk of toxicity) Irreversible liver damage Liver
transplant Abstain from alcohol Adequate diet and vitamin
supplementation
- Slide 36
- Questions 1. Hepatic encephalopathy is caused by a) Liver
failure b) Acute cholecystitis c) Kidney failure d) Acute
hepatitis
- Slide 37
- Questions 2. Sweet smelling breath can be cause by all the
following except: a) Diabetic ketoacidosis b) Pseudomonas infection
c) Alcoholic ketoacidosis d) Tetracholoroethane toxicity e)
Streptococcal infection
- Slide 38
- Questions 3. Which of the following can cause occupational
toxicity? a) Ethylene glycol b) Tetrachloroethane c) Carbon
tetrachloride d) Dihydrogen Oxide e) A & B f) A, B & C g) A
& C h) All of the above (A D)