A 60 year old male is brought to your Emergency Department by ambulance. On scene he was found with a GCS 12 and a BSL of 2.
On route he received 50mls of 50% dextrose ivi. He was vomiting profusely.
The history obtained from family (by paramedics) was that the patient was on a three day alcohol bender, which was not unusual. He was not english speaking. There was a history of malaena and oesophageal varices in the past.
He complained of Thoracic back pain and weakness
On examination
Vitals: GCS 15 BP 100/50 PR 120/min
T 35.8 RR 18/min O2 sats 99% RA
Describe and Interpret the following venous blood gas and results
pH 6.91 COHb 0.9% Glu 6.0
pCO2 36 MetHb 0.8% Lactate 25
pO2 47.2 Na 147 Hb 171
HCO3 7.2 K 4.2 Urea 8.1
BE -24.5 CL 102 Creatinine 120
WCC 27.1 N 17.0
VBG interpretation:
1) Acidaemia
2) Lactate acidosis
3) Severe metabolic acidosis – high anion gap
4) Hypernatraemia
5) Leukocytosis (with left shift)
6) Elevated Hb
7) Renal failure
Clinical interpretation:
Hypothermic, hypotensive, tachycardic, decreased GCS, vomiting, thoracic back pain, dehydration, hypoglycaemic initially
Alcohol abuse, likely chronic hepatic failure with sequelae
Overall differentials (limited list):
1) High anion gap metabolic acidosis culprits: Methanol overdose, ethylene glycol, aspirin et al.
2) Acute on chronic liver failure with alcohol ingestion (hyponatraemia would make a better case)
3) Gastroenteritis/infectious cause – I’d love to explore the back pain further
4) Many many more
Cheers,
SMW