Thread by @IM_Crit_

ICU stories (a brief one): A 40+ yo pt w hx of bipolar disorder/asthma/GERD/HTN was brought to the ED by EMS after his wife found him lethargic ("altered mental status"). Apparently, he had spent the previous 2 days isolated in his forest cabin. Upon ED arrival, he was obtunded

& was given Narcan with no improvement. Vitals: 140/90, hr 80, rr 22, afebrile, sat 97% on room air. He could respond to simple questions. CT brain was negative. Lab work/up showed Hct of 59%, wbc 11k, PLT 400k and a chemistry panel showed:

A urine drug screen was sent 👇 while patient admitted that he had probably taken more Xanax (alprazolam) pills than he should. However, he denied that he wanted to hurt himself.

The ED attending decided to admit the patient to the "Medicine" floor for dehydration & possible benzodiazepine overdose and described the plan in his note:

Besides the ED plan/note, are you concerned about anything else?

After admission to the floor, patient became more somnolent. A nurse documented NIH stroke scale of 5 & patient was re-assessed by a resident & the attending. Neuro exam did not look to them different than earlier but they ordered Neuro consult / brain MRI and EEG (for next am)

They also ordered an ABG:

With this blood gas, patient was transferred to the ICU. Osmolar gap was 30+ and methanol level was 110 mg/dl. He received fomepizole stat & later was placed on HD. He had blurry vision for 2 days but made a full recovery. He admitted that he had drank windshield washer fluid

The American Academy of Clinical Toxicology recommends that HD be considered in the presence of
metabolic acidosis, visual abnormalities, renal failure, or electrolyte imbalance unresponsive to
conventional tx and/or serum methanol level of 50 mg/dl. However, fomepizole, even w

serum concentrations > 50mg/dl, frequently eliminates completely the need for HD or allows it to be done electively. Also:
1. the metabolism of formate is enhanced by folic acid, so administration of F as adjunctive therapy is reasonable
2. bicarbonate is recommended

It is important to remember that as time passes and the toxic alcohol is metabolized, the osmolar gap decreases and the anion gap increases:

Take-home messages:
1. I am sure that ED people see hundreds of patients like this one every day and the hospitalists admit dozens of patients like this one and we, the intensivists, see only a handful of them and have the privilege of judging in retrospect. However, if a patient

with "altered mental status" has a bicarbonate of 5 on admission, then he does not have (only) benzo overdose. PERIOD.
2. I will take heat for this but I will say it: if you don't know what's going on with a patient and you can send only one test, just send a blood gas...

You may still not know what's going on but you will have a reason to send him to the ICU!

3. A poisoned (w toxic alcohol) patient can present with both a NORMAL or high osmolal gap & a NORMAL or elevated serum anion gap DEPENDING on where he is at the time course of poisoning.

Rule out the possibility at your own (and the patient's) peril...

4. "Shared decision making" is a code name for "keep the administrators happy", even if we have no clue about what's going on with the patient...

Thanks for reading!

Good reference:
nejm.org/doi/10.1056/NE…

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