1.  Case 1: An Acidic Alcoholic n A 44 yo man was found unconscious, with a suicide note and a half-empty bottle of Jim Beam. n BP 110/80HR 110RR 24 n pH 7.47 pCO 2 22pO 2 88 n Na 140 K 3.8 Cl 106 HCO 3 18 n ETOH 0.18 gm/dL

2.  Case 2: A Gapped Gipper n 30 yo M found comatose n Temp 86F, pH 6.9 n Na 147, K 4.9, Cl 105, Bicarb 5 –Anion gap 37 n Glu 166, BUN 16, Cr 1.5 n Measured Osm 331 –Osm gap 23 n Ethanol “zero”

3.  Cases 3-4: Caustic Cocktails n A sulfuric anion gap: n 33 yo M ingested "Hot Shot Drain Cleaner" containing 9% sulfuric acid n BP 110-120/palp, drooling, in pain n ET intubated shortly after arrival n Initial Na 143, K 8.1, Cl 97, HCO3 <5, –Anion gap >40 n Lactate 2.1

4.  Caustic Cocktails, continued... n Not an anion gap: n 43 yo F ingested Lysol Toilet Bowl Cleaner (HCl 8.5-9.5%, pH <1) n Pain! Serum CPK 26,812 n pH 7.19, CO2 24 n Na 144 Cl 121 HCO3 18.6 –Anion gap = 4.4

5.  A Final Stumper: n A 5 year old Laotian immigrant girl was brought to the ED at 3 AM very lethargic n History of nausea and vomiting starting at 1 AM n BP 89/42 HR 103 R 16 T 97 n Pupils 4 mm, skin normal n Mouth dry, active peristalsis

6.  Case 9 Continued... n According to the father, at 6 pm the previous evening the family had eaten a meal of steamed wild root n They collected it near the Berkeley Marina and considered it a tasty substitute for bamboo shoots n At 1 AM all 5 family members experienced nausea and vomiting; the 5 yo also had diarrhea

7.  Case 9, Continued... n Shortly after admission, the child's pupils were noted to be dilated and poorly reactive n Respirations were shallow, and the HR was 65/min n pH 6.8 pCO 2 21 pO 2 220 n Shortly after, the child had a tonic- clonic seizure

8.  Case 9, Continued... n Further Hx: n The family said a brother was taking some type of “chest medicine” n A family member was sent home to retrieve the bottle….

9.  Seizures and acidosis n A 15 year old high school student recently immigrated from Laos n Had 3 seizures at home n Unconsicous n pH 6.9 pCO2 34

10.  Smoke inhalation n A 54 year old alcoholic was found in his smoke-filled trailer by firefighters –obtunded, combative –soot on face and in nose –BP 160/100, HR 110/min, RR 22/min –EtOH = 0.08 g/dL

11.  Initial labs... n CXR = possible aspiration pneumonia n WBC = 21,000 n COHgb = 10% (after receiving 100% oxygen en route from the scene)

12.  More info... n CT scan = cerebral edema n No obvious improvement on 100% oxygen via ET tube n Discussion about HBO –monoplace chamber in the hospital

13.  Now what? n Re-examination: –rectal T 38.5 C –stiff neck? Or irritation due to ET tube? n Revisited the ATOMIC mnemonic: –LP: purulent pneumococcal meningitis!! n Treated with IV antibiotics, no HBO

14.  Acute Drug Abuse Emergencies n Common physiologic problems: –Coma –Hypotension or Hypertension –Seizures –Hyperthermia (heat stroke) n Other problems: –Date rape / Assault –Falls / Motor vehicle accidents

15.  Case 1 n 30 year old man found unconscious, not breathing n Small pupils n IV drug abuse paraphernalia

16.  Opioid Overdose n Causes: –IV heroin most common –Other sources: codeine, etc. n Activate opioid receptors in brain: –Sleepiness –Depressed respiratory drive n Treatment: –Support breathing, give oxygen –Naloxone: specific antidote

17.  Case 2 n 23 year old found on floor at a dance party n Unresponsive to pain n Occasional muscle twitching or seizure-like activity n Barely breathing n No response to IV naloxone n Awake in 2 hours

18.  GHB n Gamma hydroxy butyrate –Short-acting anesthetic agent –Rapid onset of deep coma –Lasts 2-4 hours n Precursors and chemical relatives –Gamma butyrolactone (GBL), 1,4- butanediol, tetramethylene glycol, or 2(3H)-Furanone di-hydro –Revitalize Plus, Serenity, Enliven, GHRE, SomatoPro, NRG3, Thunder Nectar...

19.  Case 3 n Another young man on the dance floor, having multiple seizures n In ER: –Unresponsive –BP 90/60, HR 140/min –Rectal T 106.5 F n Remains in deep coma, develops multiple organ failure, dies after 2 days in the hospital

20.  Stimulant intoxication n Many causes: –Methamphetamine (“crystal”, “crank”) –MDMA (“ecstasy”) –Cocaine –Various OTC products (ephedrine, PPA, caffeine, herbal and nutritional supplements) n Central sympathetic system stimulation n Activation of peripheral CV receptors

21.  Stimulants, cont. n Clinical findings: –Euphoria, alertness –Paranoia, agitation –Seizures –Increased heart rate, blood pressure n Hyperthermia is BIG life threat –Brain damage –Hypotension –Mulitple organ failure

22.  Case 4 n 17 year old found at the bottom of the staircase n Had been “huffing” gas from a can of computer key board cleaner. n 911 was called - police arrived in 2 minutes and found him pulseless, not breathing n Resuscitated but declared brain dead and expired 2 days later

23.  Solvent abuse n Variety of solvents and gases: –Toluene, xylene (in glues, paints, etc) –Trichloroethylene (“White-out”) –Freon –Nitrous oxide –Butane n Main danger: cardiac arrhythmia n Long-term brain damage with toluene, nitrous oxide