SomebodyLikeBLUE…--TwoCasesofPoisoning.ppt

Somebody Like BLUE…-- Two Cases of Poisoning By Chan Yuen Sze, Christina Resident of PMH ICU Case 1 M/22 Mild mental retardation, education up to F.5 in special school Lives alone. Poor social and family support. NKDA, smoker and drinker History of suicidal attempt by ingestion of insecticide History of substance abuse and panadol poisoning Defaulted FU from Psychi Worked as security guard in Park Island Admitted PMH 18-7-08 for ingestion of ~ 200ml of “purple blue fluid” in the security kiosk at ~ 00:30 am after being scolded by his supervisor during work Attended to AED on 18-7-08 at ~ 02:00 am In AED Presented with semi-consciousness and drooling of saliva in AED BP 115/52, P 107 regular Temp 37.5C Hstix 5.1 SpO2 100% on RA, RR 16/min PEARL 3mm, GCS E4V4M6. Sleepy but arousable Buccal mucosa normal, no burn marks No vomiting Chest clear, no SOB CXR clear, no pulmonary edema No gastric lavage / activated charcoal given in AED 1st set of blood result on 18-7-08 at 03:00 am Electrolyte and L/RFT normal VBG: pH 7.43, pCO2 4.63, pO2 6.18, HCO3 22.4, BE -2.0, SaO2 83.8% Ethanol level 2 mmol/L Paracetamol 66 umol/L Salicylate 0.30 mmol/L What are you going to check at this moment? What is your differential diagnosis? Blood result on 18-7-08 at 12:56 Repeat VBG: pH 7.30, HCO3 21.8, BE -4.7, pCO2 6.07, pO2 5.03 Blood result on 18-7-08 at 20:00 Repeat ABG: pH 7.34, HCO3 18.1, BE -7.6, pCO2 4.53, pO2 16.38 Anion gap Na – Cl – HCO3 136 – 108 – 18.1 9.9 mmol/L normal 10 +/- 4 Measured Plasma osmolality 324 mmol/kg N 270-290 mmol/kg on 18-7-08 at 03:00 am Repeat Measured Plasma Osmolality 331 mmol/kg on 18-7-08 at 20:00 Calculated Plasma osmolality 2x[Na] + [glucose] + [urea[ 2 x 136 + 5.6 + 2.7 272 + 5.6 + 2.7 280.3 mmol/kg Osmolar Gap Measured P osm – Calculated P osm 331 – 280.3 50.7 normal 10-15 What is the causes of elevated osmolar gap? The Osmolar Gap is another important diagnostic tool for differentiating the causes of metaboli