AB098. SOH24AB_117. Toxic alcohol ingestion results in significant hypocarbia & low bicarbonate levels

Background: A 43-year-old female presented to our emergency department with abdominal discomfort, hypotension, and confusion. Her recent history was significant for alcohol intake and travel back from Lithuania. Her initial arterial blood gas exhibited a metabolic acidosis with an increased anion gap. Some of its results were markedly abnormal: a bicarbonate level less than 3 mmol/L (milli mol per litre) (normal: 25–35 mmol/L) and a partial pressure of arterial carbon dioxide (PaCO₂) less than 2 KPa (kilo pascal) (normal: 4.5–6 KPa).

Methods: Toxicity secondary to a toxic alcohol was suspected. A focused ultrasound in intensive care (FUSIC) heart scan revealed hyperdynamic cardiac chambers, a very fluid tolerant inferior vena cava (IVC) and normal lung ultrasound artifacts bilaterally (A-lines). The hypotension required treatment with intravascular (IV) fluid resuscitation. One litre of IV isotonic bicarbonate over 30 mins followed by a second litre over 1 hour was given while establishing central (dialysis catheter) and arterial IV access and contacting TOXBASE.

Results: As the patient’s arterial blood gas values started to improve, abnormal renal indices, a persistent acidosis, anuria, and the likely ingestion of a toxic alcohol meant that dialysis was indicated, and we moved the patient to intensive care unit (ICU) to facilitate this. We commenced high flow oxygen, IV dexmedetomidine for anxiolysis and managed to avoid endotracheal intubation. We administered fomepizole.

Conclusions: The patient’s toxicology screen was negative for ethylene glycol and other known toxins. We did not identify the ingredients of the toxic home brew but the patient admitted to its ingestion upon clinical improvement. This case shows that there is a role for large volume resuscitation with isotonic bicarbonate in young patients who have ingested a toxic alcohol and can compensate for the resultant CO₂ production.

Keywords: Toxic alcohol; isotonic bicarbonate; hypocarbia; metabolic acidosis; focused ultrasound in intensive care heart (FUSIC heart)