Topic 9-10 D

Q-1

I remember a grandma in her 80’s age admitted to ICU, came to ED c/o abdominal pain and dyspepsia and heartburn and she is self-treating at home with one spoon of baking soda every day sometimes twice a day for months and now she cannot get any relief of symptom with her home remedy and some non-specific complaints like feeling lethargic, abdominal pain, constipation. Patients' who overdosed on sodium bicarbonate cause metabolic alkalosis with high HCO3 levels sometimes combined with acidosis, major electrolyte imbalances such as hypokalemia, hypernatremia. If severe hypokalemia may go into flaccid paralysis, tetany, hyporeflexia, and rhabdomyolysis. Metabolic acidosis takes a long time to correct and is hard to treat.

Physical exam: A thin body-built female patient, living independently, very cachexic appearing. Minimally confused, Breathing 30’s and Bp 85/65, HR-100’s. some epigastric tenderness and pain on the upper and mid abdominal area. Report constipation and having bowel movements once a week with anorexia.

Diagnostic workup: CBC showed Hb-low around 8-anemia. BMP showed a high CO2 level with k-3.1, NA- 155, Creatinine-2.1. Blood sugar-98. ABG showed pH- 7.49, pO2 70, PCO2- 56, HCO3 level was around 50’s. Magnesium level 1.5, serum and urine osmolality, and urine sodium level, chest X-ray without any acute findings, EKG sinus tachycardia with non-specific T wave abnormalities, and x-ray KUB showed dilated large bowel loops with fecal matters.

Differential diagnosis: sodium bicarbonate toxicity, chronic constipation, GERD.

1. Sodium bicarbonate toxicity: -

· Admit in ICU for close monitoring for arrhythmia,

· supplementary oxygen.

· ABG showed high pH, CO2, HCO3 possibly secondary to intentional toxic ingestion of baking soda for abdominal symptom relief.

· hypernatremia and creatinine elevation possibly related to dehydration (Hypovolemic).

· will start slow hydration with 0.9% normal saline followed by ½ NS chronic hypernatremia that occurs in a duration of >48 hours need to be treated at a low speed due to cerebral edema risk during treatment (Moradi, Sabzghabaei, & Kalantar, 2020).

· Correct hypokalemia with PO supplements as well as dietary modifications. Oral replacement is normally sufficient for most patients with mild hypokalemia and minimal symptoms (Vavruk, Martins, & Nascimento, 2021).

· Correct Magnesium with IV magnesium which will correct hypokalemia as well.

· Hold all antacids and nephrotoxic agents.

· Follow up ABG, BMP with electrolytes to evaluate the progress of treatments. The shift of potassium in and out of cells under multiple influences and as potassium replenishes, checking the level for several days is needed to determine potassium stability (Vavruk, Martins, & Nascimento, 2021).

1. Chronic constipation: -

· Laxatives and enema if laxatives did not relieve constipation.

· Encourage food and fluids, a high fiber diet, or fiber supplement.

· Continue laxative/stool softener daily as needed.

· Abdominal massage has been found as an effective method for constipation management in the elderly (Baran, & Ates, 2019).

· Education and counseling on baking soda toxicity/overuse.

1. GERD: -

· Start PPIs i.e., pantoprazole 40 mg po daily. PPIs are the most effective medical therapy as compared to all the other medical therapies in controlling symptoms of GERD (Sandhu, & Fass, 2018).

· Consult GI for upper GI scope to evaluate gastritis/peptic ulcers if no relief with PPIs.

· Patient education on lifestyle modification such as tobacco cessation, alcohol, chocolate, caffeine or coffee, citrus, mint or spicy food, elevating the head of the bed, avoid eating 3 hours prior to bedtime, sleeping on right decubitus position for sleep, sleep hygiene (Sandhu, & Fass, 2018).

Reference

Moradi, A., Sabzghabaei, F., & Kalantar, M. (2020). The Available Clinical Approaches to the Management of Patients with Acute and Chronic Hypernatremia. Open Access Macedonian Journal of Medical Sciences, 8(F), 1-10. Retrieved from https://oamjms.eu/index.php/mjms/article/view/4270

Sandhu, D. S., & Fass, R. (2018). Current trends in the management of gastroesophageal reflux disease. Gut and liver, 12(1), 7. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5753679/

Baran, A., & Ates, S. (2019). The effects of abdominal massage in the management of constipation in elderly people: a randomized controlled study. Topics in geriatric rehabilitation, 35(2), 134-140. Retrieved from https://journals.lww.com/topicsingeriatricrehabilitation/Abstract/2019/04000/The_Effects_of_Abdominal_Massage_in_the_Management.9.aspx

Vavruk, A. M., Martins, C., & Nascimento, M. M. (2021). Management of hypokalemia. Sat. Retrieved from https://wbhf.walterbushnell.com/index.php?option=com_k2&view=item&id=13:management-of-hypokalemia&Itemid=326

Q-2

Accidental "Drain-O" Ingestion

Drain-O is a common household substance used for clearing clogged drains and most people keep it either under their sink, or in the garage. Two populations that are most at risk are those who fall into dementia/Alzheimers, and pediatrics (Acehan, Satar, Gulen, Avci, 2021);(Caganova et al., 2017).

Drain-O is an alkaline substance that is composed of sodium hydroxide, sodium nitrate, sodium chloride and aluminum and registers at an 11 on the pH scale (Caganova et al., 2017);(Acehan, Satar, Gulen, Avci, 2021) When ingested it is caustic to the body's tissues, and in this case, it can cause severe esophageal damage with colliquative necrosis (Caganova et al., 2017). This can further be complicated by pneumonia, respiratory failure, bleeding, perforation, strictures, and fistulas (Caganova et al., 2017).

Physical findings and diagnostic findings begin at the site of ingestion as that tissue has been exposed to the chemical the longest (Caganova et al., 2017). So for example, in the oral route, the mouth and tongue will appear to be edematous and possibly have some blistering (Acehan, Satar, Gulen, Avci, 2021);(Caganova, 2017). Sometimes the patients will present with drooling, vomiting, upper airway edema, voice changes, stridor, and overall respiratory distress (Acehan, Satar, Gulen, Avci, 2021);(Caganova, 2017). If a patient presents with concomitant hematemesis then usually the skin has dissolved enough somewhere in the esophagus to allow for bleeding to occur (Acehan, Satar, Gulen, Avci, 2021);(Caganova, 2017).

Treatment in the oral ingestion of draino begins with an accurate HPI (Acehan, Satar, Gulen, Avci, 2021);(Caganova, 2017). How much was ingested, how long has it been, why they ingested the substance, and the route of ingestion are all important questions that can help bridge the gap of determining the treatment and plan (Acehan, Satar, Gulen, Avci, 2021);(Caganova, 2017). Supportive treatment includes intubation and ventilation on patients who are in respiratory distress or have excessive drooling and voice changes (Acehan, Satar, Gulen, Avci, 2021);(Caganova, 2017). Another intervention is endoscopy to determine the extent of injury such as necrosis and for removal of the necrotic tissue (Acehan, Satar, Gulen, Avci, 2021);(Caganova, 2017).

Differential diagnoses include trauma, congenital abnormalities, and direct-heat burns (Acehan, Satar, Gulen, Avci, 2021);(Caganova, 2017). The workup and HPI will help discern between the type of insult (Acehan, Satar, Gulen, Avci, 2021);(Caganova, 2017).

References:

Acehan, S., Satar, S., Gulen, M., & Avci, A. (2021). Evaluation of corrosive poisoning in adult patients. American Journal of Emergency Medicine, 39, 65–70. https://doi-org.lopes.idm.oclc.org/10.1016/j.ajem.2020.01.016 Caganova, B., Foltanova, T., Puchon, E., Ondriasova, E., Plackova, S., Fazekas, T., & Kuzelova, M. (2017). Caustic Ingestion in the Elderly: Influence of Age on Clinical Outcome. Molecules (Basel, Switzerland), 22(10), 1726. https://doi.org/10.3390/molecules22101726

Q-3

Paraffin is a low-viscosity hydrocarbon that poses major risks of injury either through ingestion or through inhalation of smoke and fumes. It can be found in products including candles, creams, waxes, and torch fuel. Various factors that contribute to unintentional exposures include inadequate adult supervision, improper storage techniques such as storing in unlabeled easy-to-open containers, and physical properties such as a colored liquid appearing like juice or an odor resembling a pleasant fragrance such as citronella or lemongrass which may also contain other toxic substances like insect repellant (Ellis, Krug, Robertson, Hay, & MacIntyre, 2016).

 The primary health risk from ingestion is unintentional aspiration due to its low viscosity. Significant pulmonary injury including chemical pneumonitis, respiratory distress, and death is possible following aspiration. Patients may present with a headache, burns in their mouth, esophagus, and laryngeal edema. Effects on the central nervous system following gastrointestinal absorption include dizziness, vision changes, restlessness, ataxia, drowsiness, euphoria, convulsions, coma, and death. If the paraffin contains a dye, a person who has an allergy to that dye may develop tongue and throat swelling, wheezing, and trouble breathing (Ellis et al., 2016).

 Differential diagnosis would be based on history and would include carbon monoxide poisoning, toluene toxicity other hydrocarbons such as motor fuel, paint thinner, cleaning agents, lotion, industrial solvents, barbiturate, and benzodiazepine toxicity.  Work up would include an ABG, CBC, serum glucose and electrolytes, BUN, Cr, LFTs, ammonia, CK, and urine drug screen. Other tests would include EKG to identify dysrhythmias, chest radiograph to identify chemical pneumonitis, and pulse oximetry, (Brown & Armstrong, 2021). Treatment varies and depends on the amount and type ingested and whether or not the patient is symptomatic and would involve consultation with poison control. Asymptomatic patients require close monitoring of respiratory status, repeat chest Xrays, and should be NPO. Patients with severely depressed mental status severe respiratory distress, those who are unresponsive to oxygen and beta-2 bronchodilators should be intubated. Nasogastric lavage would be performed when there is a risk of systemic toxicity from GI absorption, and approximately 60 minutes after ingestion. Activated charcoal is contraindicated in hydrocarbon poisoning as they do not bind hydrocarbons and increase the risk of hydrocarbon aspiration (Brown & Armstrong, 2021).

 

 

Brown, K. W., & Armstrong, T. J. (2021). Hydrocarbon Inhalation. In StatPearls. StatPearls Publishing.

Ellis, J. B., Krug, A., Robertson, J., Hay, I. T., & MacIntyre, U. (2016). Paraffin ingestion--the problem. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 84(11), 727–730.