1. A lady in coma Law Chi Yin PYNEH

2. A lady in coma ► 98/F ► Found unconscious in bed at 5:00 am ► No special complain in recent days ► No history of injury ► Brought in by ambulance ► Accompany with her son who is Chinese medicine practitioner

3. A lady in coma ► Her son showed you a bottle of antiseptic solution ► She was suspected drinking the solution last night

4. A lady in coma ► No external wound ► GCS 3/15 ► BP 120/68 mmHg, pulse 128 bpm ► Temp 36.8 o C, ► RR 22 / min ► SpO 2 91% in 100% O 2

5. A lady in coma ► She had skin eczema ► requiring home skin care with antiseptic solution ► She got history of suicidal attempt before ► No other empty bottles of pills, ► No win bottle at her home ► No history of DM

6. A lady in coma ► She was intubated in AED ► CXR showed lung fields haziness ► She was admitted to medical ward for toxic alcohol intoxication

7. A lady in coma ► Investigation  Na140  K3.3  Cl107  Urea8.5 (<6.5)  Cr203(<97) ► Investigation  WBC 29.3  Ca2.13(2.2-2.6)  Amylase 285(<125)  Sugar20.5

8. A lady in coma ► Investigation  pH7.236  pCO23.04  pO239.34  HCO39.5 (20-26)  Base excess-15.9 (-3 to 3)  O2 saturation99.6

9. A lady in coma ► Investigation  Serum osmolality 352 mOsm/kg(289-308)  Serum toxicology ► Serum level of paracetamol, salicylates and ethanol was normal  Urine tests ► Negative for barbiturates, benzodiazepines, cannabinoids and opiates

10. A lady in coma ► Problems  Coma  Suspected aspiration pneumonia  Metabolic acidosis  Increase serum osmolality

11. A lady in coma ► Anion gap =Na + k - Cl –HCO3 =140+3.3-107-9.5 =26.8 (normal 8-12) ► Elevated AG

12. A lady in coma ► Osmolality gap =measure osmolality – (2x Na + urea + glucose) =352-(140x2 +8.5 -20.5) =352-309 =43 (normal <10) ► Elevated OG

13. A lady in coma ► DDx of anion gap metabolic acidosis  Mudpiles: ► methanol, ► Uremia, ► DKA, ► Paraldehyde, ► INH/Iron, ► lactate, ► ethylene glycol, ► Salicylates

14. A lady in coma ► DDx of anion gap metabolic acidosis  Kult: ► Ketones (DKA, alcoholic, salicylates) ► Uremia ► Lactate (hypoxia, shock, CN poisoning, seizures, liver failure) ► Toxic alcohol

15. A lady in coma ► DDx of increase osmolality gap  Medie ► Methanol/ metformin lactic acidosis ► Ethylene glycol ► DKA/ diuretic (mannitol) ► Isopropyl alcohol ► Ethanol

16. A lady in coma ► The bottle contained 75 % isopropyl alcohol ► His son estimated that her mother might drink up to 50 ml of the solution ► She had drunk the solution 8 hours before she presented to emergency room

17. Isopropyl alcohol

18. ► Isopropanol or 2-propanol ► Skin disinfectant, and popularly name as rubbing alcohol ► Commonly used as a window cleaner and paint remover and industry solvent ► Gasoline additive for dissolving water or ice in fuel lines

19. Isopropyl alcohol

20. ► It metabolizes to acetone in the liver by alcohol dehydrogenase. ► 80% absorbed dose is excreted by the kidneys as acetone ► 20% being excreted unchanged. ► The acetone is also excreted in the lungs, saliva, and gastric juices.

21. Acetone ► Acetone, also called dimethyl ketone ► An excellent solvent for oils and greases ► It is one of the least toxic of the many organic solvents used ► Clinical effects to human body is similar to ethanol.

22. Isopropyl alcohol ► It is two-three times more potent than ethanol as a CNS depressant. ► The breakdown product, acetone, is also a CNS depressant. ► Doses of above 20 ml of rubbing alcohol (70% solution) may produce toxic effects.

23. Isopropyl alcohol intoxication ► Poisoning can occur through skin absorption, oral ingestion, or inhalation ► Symptoms of intoxication occur within 30 minutes ► Symptoms include:  flushing, headache, dizziness,  mental depression, nausea, vomiting  anesthesia, and coma

24. Isopropyl alcohol intoxication ► Symptoms may occur as 1 ml/kg of a 70% solution. ► The lethal dose may be as low as 240 ml (2 to 4 ml/kg). ► Death has been reported at a blood level of 150 mg/dl (25 mmol/l) ► Survival after dialysis has been reported at levels as high as 560 mg/dl

25. Isopropyl alcohol intoxication ► No initial excitatory phase (well recognized with ethanol intoxication) ► odor of acetone (sweet ketotic scent) ► Myocardial depression and severe hypotension in large dose intoxication ► Less common :  renal tubular necrosis, hemolytic anemia, acute myopathy, and hypothermia

26. Isopropyl alcohol intoxication ► Has greater osmolality gap in four toxic alcohols ► Has only mild anion gap metabolic acidosis (similar to ethanol intoxication) ► Exception is for patient has hypotension, hypoxia, etc ► Similar to ethanol, It has significant hypoglycemic effect.

27. Treatment of Isopropyl alcohol intoxication ► ABC care ► Close observation of vital signs ► Supportive care ► Prevention of complications ► DDx

28. Treatment of Isopropyl alcohol intoxication ► Gastric lavage and charcoal of a large, recent dose of isopropanol ► Hemodialysis for patients with coma and hypotension with or without a level of 400- 500 mg/dl. ► No antidote

29. Paediatric consideration ► Case reports of isopropyl alcohol intoxication  accidentally ingest  Dermal/inhalation exposure in children during isopropyl alcohol sponging for control of fever

30. Outcome ► She died few days later ► Serum level of isopropyl alcohol was not checked ► Likely causes of death  Isopropyl alcohol intoxication  Complicated with aspiration pneumonia and renal failure