This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.
Why it Matters
While toxic alcohol ingestions requiring treatment are relatively rare, patients presenting with a profoundly altered mental status are not. This case highlights key features of each, including:
- The need for a broad differential in patients with an altered mental status (especially when there is absolutely no relevant history available!)
- The importance of identifying and working through causes of an anion gap metabolic acidosis
- The empiric and definitive treatments of a toxic alcohol overdose
EMS has just brought you to a patient with a GCS of 3. He was found in the back alley behind a drug store with no identifying information. He is not known to EMS or to your department. He appears to be in his 30s or 40s.
A 46 year-old male presents with a GCS of 3 after being found in the back alley behind a drug store. The team will need to work through a broad differential diagnosis and recognize the need to intubate the patient. If they try naloxone, it will have no effect. After intubation, the team will receive critical VBG results showing a profound metabolic acidosis with a significant anion gap. The goal is to trigger the team to work through the possible causes of an elevated anion gap, including toxic alcohols.
Download the case here: Toxic Alcohol Case
ECG for the case found here:
(ECG source: http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)
Post-intubation CXR for the case found here:
(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)