Thread by @RosenelliEM

Time for some #SpacedRepetition: @CPSolvers

Chat recap of the #ClinicalPearls #VirtualMorningReport
w/ @StephVSherman @DxRxEdu @rabihmgeha

June 22th Day 79: clinicalproblemsolving.com/morning-report…

Case Overview by @haematognomist

Prior to case @medrants shared some pearls on the prior VMR case:

Patients with Lemierre syndrome have a high risk of new thromboembolic complications, clinical sequelae and death: an analysis of 712 cases onlinelibrary.wiley.com/doi/full/10.11…

Let's start with an initial problem representation:

A 49-yo M was found unresponsive laying in a park w/ an almost empty trazodone bottle that was filled layer, he was obtunded on exam w/o signs of trauma and found to have ⏫AG, ⏫Cr, ⏫ Osm Gap, ⏫QTc

A good pearl for those presenting in the ER with AMS:

“ABC IV O2 Monitor Finger Stick"

DONT of AMS - dextrose, oxygen, naloxone, thiamine

If 0.4 mg naloxone doesn't work, give more. With new synthetic opioids, they need > than usual 0.4 mg, go for 2mg pubmed.ncbi.nlm.nih.gov/31665765/

Trazodone is a 5HT2 and alpha 1 receptor antagonist

Thankfully When taken alone in overdose, trazodone appears to have limited toxicity. pubmed.ncbi.nlm.nih.gov/3771499/

An overdose on it has been reported to cause serotonin syndrome

He has no signs of serotonin syndrome like hyperthermia, tachycardia, hypertension, altered mental status, agitation, diaphoresis, tremor, myoclonus, and hyperreflexia

Trazodone possesses minimal anticholinergic properties, and thus has less cardiotoxic potential

It can and has been shown to cause prolonged qTC and maybe AV block, hypotension ncbi.nlm.nih.gov/pmc/articles/P…

Great point from @DxRxEdu . How much of an HPI can be constructed by collateral information - from bystanders/family, to med bottles and pharmacy detective work, etc.

Remember when the ECG says prolonged qTC, calculate your own to confirm on MDCalc, mdcalc.com/corrected-qt-i…

@DoctorVig tweetorial on QTc calculation:

https://twitter.com/DoctorVig/status/1265741266060546048

Urine would be helpful to look for any crystals which can be seen from different alcohol ODs which could also cause anion gap acidosis

Note with the ⏫anion gap and the normal bicarb - the patient has an⏫ anion gap acidosis and a metabolic alkalosis

We need a serum osm!

all alcohols cause osmotic gap, all but isopropyl alcohol cause anion gap

This will help us look indirectly for either a methanol or ethylene glycol toxicity

But have to also check ethanol level Because ethanol can cause an osm gap

mdcalc.com/serum-osmolali…

Remember there are two formulas for this calculation for x or mol weight of alcohol

The traditional equation
(2 × Na + (BUN / 2.8) + (glucose / 18) + (ethanol / 4.6)

Or the Purrsell equation
(2 × Na + (BUN / 2.8) + (glucose / 18) + (ethanol / 3.7)
sciencedirect.com/science/articl…

This 4.6 or 3.7 number is what we call the fudge factor. It can truly offset whether or not you have an OSM gap

Fun Fact: In residency, I authored a study that looked directly at this using volunteers to drink and calculate what the true number was. pubmed.ncbi.nlm.nih.gov/23641935/

Some said it was the best residency project.

We found the contribution of ethanol to serum osmolality (k) was found to be 4.25.

This indicates that ethanol contributes more to total serum osmolality than would be predicted for an ideal solute.

back to the case, remember in a toxic ETOH OD you get an elevated osm gap first and then next an elevated AG

A great resource from the US, Poison Control Centers. aapcc.org/centers

Just another reminder of the MIST schema here for AMS: clinicalproblemsolving.com/wp-content/upl…

Need a QUICK SEARCH for drugs on the QTdrugs Lists
crediblemeds.org

Best lead to check QtC is Lead II, V2/V3 are not great b/c of repol often results in U wave…the computer is only right ~ 75% of time in the calculation.

Need another pneumonic for an AG acidosis

@medrants uses KILU - keto acidosis, ingestions, lactic acidosis, uremia

Others have been taught by a neph that AG > 20, a metabolic acidosis is present, regardless of bicarb or pH

Final Dx Ethylene Glycol Overdose

Treatment with IV or oral ethanol to keep serum ETOH >100, if not give fomepizole

But don’t forget the beauty of the gut. It absorbs stuff… with stunning efficiency. PO ethanol will be in your veins quite quickly. litfl.com/ethanol/

ETOH Competitively blocks the formation of toxic metabolites in toxic alcohol ingestion by having a higher affinity for the enzyme Alcohol Dehydrogenase (ADH)

A review on Ethylene Glycol Toxicity
statpearls.com/kb/viewarticle…

Remember that ethylene glycol & methanol are intoxicating

Here´s a mini-thread in Spanish talking about this vodka use

https://twitter.com/almagoch/status/1260745890710446080?s=08

Urine slide of calcium oxalate crystals - ethylene glycol

EG can also prolong the qTc

Teaching points by @sukritibanthiya clinicalproblemsolving.com/wp-content/upl…

@matstomato @AnandJag1 @StephVSherman @MargaretL16 @aoglasser @ETSshow @gradydoctor @MohitHarshMD @HannahRAbrams @SmithaGaneshan @jackpenner @TheRealDSrini @MattSakumoto @medrants @RachelBigley1 @k_vaishnani @MeerkatMirson @matstomato @zoyaqureshy @tony_breu @ddeng_22

@Sharminzi @ArsalanMedEd @ecvasti @JonathanRyderMD @RezidentMD @GurleyGuy @appyjumpindaze @justalisongrace @DavidTHLam @BethGay45 @BrandonKinneman @rongejman @BryanCUlrich @victorekuta @danaamara1 @NishaSunkuMD @pri_athavale @BhavyaVarma12 @sargsyanz @StephVSherman

@appyjumpindaze @noahrosenberg @JFBirnbaum @chioma_ndukweau @andressa__k @PeytonNesmith @blairgolden @BP76104 @Gurpreet2015 @mBohlega @INizamuddinMD @AlexHorneMD @EricaLCrosley @AJ_Kurtzman @miniisms @dsouzl @AaronLTroy @danielgauvin07 @AdamLongMD @d_dressler92 @Chris_Lees_

@tmodarressi @DanielleEngskow @AnneArnason @AmandaGarfinkel @mBohlega @Tapatio117 @DoctorVig @travishughes @activist_doc @franklybryan @_HarryPaul_ @Baker_C23 @FZghyer @RamlaKasoziMD @_blake_smith @LizzyHastie @AzeemRathore_ @AchantaAditya @Jcortesizaguirr @ShrutiKoti

@Azooz_Asbeutah @saipeeps @JordanSell22 @RizwanDania @Kaitlyn_Rogers9 @LawrenceWuMD @buckeye_sanjay @dmottacalderon @vikramagn @maheen_ihsan @efloyd14 @cobbnotgrey @Azooz_Asbeutah @onsarigo93 @Dayyan95 @tarheel_doctor @Anouf14 @VCU_IMRes @coyefish379 @amrmousa96 @Elizabe19893579

@Gurleen_Kaur96 @AshleyGWallace @Vandylism @RWBonner91 @abhiappukutty @PeguyTelusma @3owllearning @arturohdez_i @PaulKunnath @medrachel @sukritibanthiya @abdallah_tom @DoubleDawgMD @Anand_88_Patel @MikeRoseMDMPH @GurleyGuy @JoshMedPeds @AndreaAnampaG @AnthonyPensa @lakh_malla

@PGuptaMD @YihanYangMD @DanielCLiauw @ASanchez_PS @AbelJosephMD @BrentChamMD @AndreaAnampaG @this_is_svenka @SurajNagaraj @dminter89 @Doc_Fomin @AnnKumfer