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)