Good morning! Please see above for a response to last week’s tragedy.
44 yo female presenting with nausea, vomiting and abdominal pain. Patient is a chronic alcoholic with no other drug use admitted. Patient is tachycardic to 116 and hypotensive 90/68. She is alert and oriented x 3 but actively vomiting clear non-bilious and non-bloody vomit. She is tender in the epigastric and ruq. No tremors, jaundice or significant findings on exam. She has a Na 139, K 4.5, Cl 91, Co2 5, Bun 16, Cr 1.1. Her pH and lacate is 7.08 and 8.5, respectively, her urine dipstick contains ketones. There is no osmolality gap. What is your next best step in management after starting normal saline fluids?
A. CT scan of the abdomen
B. Thiamine and glucose infusion
C. Phosphate level
D. Abdominal x-ray
In this patient with a gap acidosis most likely relating to her chronic use of alcohol, the typical treatment of fluids and most importantly fluids with glucose and thiamine to help the nutrition depleted patient to improve their acid-base imbalance.
Alcoholic ketoacidosis usually develops in chronic alcoholics given their pan-nutritional deficiency status, causing the body to make ketones from the fasting state of alcohol only intake combined with low to none normal dietary food sources.
Patients, however, who develop marked hypophosphatemia are in significant risk for life-threatening sequelae including myocardial dysfunction or encephalopathy. Therefore, it is very important to ascertain the phosphate levels in such individuals to replet such a deficiency. Levels in a patient can be normal, but once treatment starts the insulin the body starts producing can drive extracellular phosphate intracellularly causing a drop in the level.
Although this occurs 12-36 hours after treatment, depending on where the level of phosphate is or how long the patient has been in the emergency department for, it is important to keep that in mind in the treatment of AKA.
Thanks to Dr. Hansen for his morning report.