Courtesy of Jen Galjour.
28M presents obtunded. EMS reports open bottle of antifreeze next to patient on scene. Initial vitals are 98.0 130 90s/50s 37 96%. Super stat shows pH 6.8, HCO3 8, lactate 12. Patient is swiftly intubated. You initiate therapy for ethylene glycol poisoning.
1) Will fomepizole help this patient?
2) Will sodium bicarb help this patient?
1) You are probably behind the 8-ball on this one for fomepizole. Patient needs emergent hemodialysis. Indications for dialysis include high anion gap metabolic acidosis or evidence of end-organ damage (e.g. vision loss, renal failure). There are no hard numbers for a pH threshold but <7.3 is reasonable in a certain toxic alcohol ingestion or <7.1 in a suspected one.
2) Yes. Give bicarb while awaiting HD. Not to chase the pH but because deprotonation of EG metabolites makes them less permeable to tissues, and promotes excretion (urine alkanilization). Give a 1-2 mEq/kg bolus followed by infusion.