15 month male ingestion

[pbruss]

15 month old male brought in by mom one hour after drinking 100 ml of a Proactive facial cleanser solution. she does not have the bottle and dose not know which specific product that it is. you have no way of tracking that information down. mom states child has been fussy since then but he is consolable and denies any sob, vomiting, or other symptoms.

in the ED the patient is mildly tachycardic but the rest of the vitals are WNL. he is fussy but consolable, not toxic in appearance, alert, interactive and in no acute distress. you can not identify any acute abnormalities on physical exam.

there are no signs of abuse or neglect. The mom seems appropriately concerned, she is nice and reasonable but not the brightest person in the world. 

Based on the above information, what would be your treatment in the ED? no multiple choice on this one.

[Bjs04f]

Facial wash usually contains benzoyl peroxide which has an msds showing oral toxicity, vitamin a which has a higher threshold for toxicity, and other alcohols. Get a BMP, cxr, call posiom control. What did oropharynx look like and lungs sound like. Labs are looking for gap osmolar or anion and cxr looking for early ards.

[Bjs04f]

There's always concern for this being caustic and causing esophageal erosions or inhalational injury. The tachycardia could be the only sign that something is wrong

[pbruss]

ripping summation. this kid had Ph of 7, anion gap of 25. lactate of 4 and osmolar gap of 40. no caustic signs on exam and no free air on x-ray. never know what the culprit was but kid was transferred to nearest Peds tertiary center.

teaching points:

if you remember my tox lecture, anion gap, ph and EKG is were I start to look for life threatening toxicity in unknown situation. his keg was fine but anion gap and acidosis led to further testing and treatment.

DO NOT IGNORE VITAL SIGNS. some of you I have worked with know that I like to have you address an abnormal vital sign in some way, either with pertinent testing/treatment, or explanation of clinical relevance in the chart : "reviewing old records pt is always tachycardic", "BP is up because pt has not taken their BP meds today yet and has no signs or symptoms of end oran involvement from elevated BP thus no further testing or treatment is indicated", "the HR was re-checked after treatment and is now normal and there is no clinical correlation between abnormality in vital signs and patient's history, physical exam and chief complaint", ect". 

remember, in cases where a doctor lost a malpractice suit, an abnormal vital sign was the most common finding in the documentation.

[pbruss]

turns out the probable ingredients in the face wash was Witch Hazel and Glycolic Acid. talked to Dr. Izack who suggested i write this case up  and submit to journal.

Anyone want to write this up and get published? i am sure would count as your academic requirement.

[drizsak]

Remember the Mnemonics:

The newest mnemonic was proposed in The Lancet reflecting current causes of anion gap metabolic acidosis: [3]

G — glycols (ethylene glycol & propylene glycol)
O — oxoproline, a metabolite of acetaminophen
L — L-lactate, the chemical responsible for lactic acidosis
D — D-lactate
M — methanol
A — aspirin
R — renal failure
K — ketoacidosis, ketones generated from starvation, alcohol, and diabetic ketoacidosis

The mnemonic MUDPILES is commonly used to remember the causes of increased anion gap metabolic acidosis.[4][5]

M — Methanol
U — Uremia (chronic kidney failure)
D — Diabetic ketoacidosis
P — Propylene glycol ("P" used to stand for Paraldehyde but this substance is not commonly used today)
I — Infection, Iron, Isoniazid, Inborn errors of metabolism
L — Lactic acidosis
E — Ethylene glycol (Note: Ethanol is sometimes included in this mnemonic as well, although the acidosis caused by ethanol is actually primarily due to the increased production of lactic acid found in such intoxication.)
S — Salicylates