Carolinas Core Concepts Core Concepts in EM; a repository for Carolinas lecture summaries.


Toxic Alcohols

Marsha Ford, MD

  • Methanol Poisoning Suspected when:
    • Anion Gap metabolic acidosis with no obvious etiology and refractory to sodium bicarb
    • Acidosis + visual deficits
  • Osmolarity maybe unreliable as level decreases with methanol metabolism
  • Ketosis without acidosis is isopropyl alcohol toxicity until proven otherwise

Drugs Of Abuse: What’s New (In) Drugs

  • The most prominent adulterant in cocaine is levamisole (found in 70% of seized cocaine in the US), which predisposes to agranulocytosis and necrotizing vasculitis.
  • Black tar heroin currently makes up about 2/3 of the US market and is frequently contaminated with clostridia.  Tetanus, wound botulism, and clostridial necrotizing fasciitis are risks.  Make sure all heroin users are up-to-date on tetanus immunizations.
  • Bath Salts primarily cause a stimulant toxidrome, and can involve fatal hyperthermia, rhabdomyolysis, and acute renal failure.  Treat with benzos and aggressive cooling as needed.
  • Synthetic cannabinoids (K12) can cause nausea, vomiting, syncope and seizures.  Treat with benzos as needed.  Of note, K12 does not show up on a standard drug screen, as it does not share key structural similarities to THC.

Respiratory Master Class

  • VBG's have supplanted ABG's in the emergent analysis of acid/base status.  The venous pH is different by only 0.05 if the pH is 7.2 or higher.   Similarly, an abnormal venous lactate is 100% sensitive for an abnormal arterial lactate.
  • Pa02 measurements detect O2 levels dissolved in plasma, not bound to hemoglobin.  This will be falsely elevated in cyanide or carbon monoxide poisoning!
    • Gennis PR, et al.: The usefulness of peripheral venous blood in estimating acid-base status in acutely ill patients. Ann Emerg Med 14(9):845, 1985.
    • Weil MH, et al.: Difference in acid-base state between venous and arterial blood during cardiopulmonary resuscitation. N Engl J Med 315(3):153, 1986.
    • Younger JG, et al.: Relationship between arterial and peripheral venous lactate levels. Acad Emerg Med 3(7):730, 1996.