“Unresponsive” continued

High-Anion Gap Metabolic Acidosis (“HAGMA”)

  • Note how the labs were significant for an acidemia (pH < 7.35) with an anion gap of 21. Respiratory compensation is appropriate, as calculated using Winter’s Formula
  • Differential diagnosis includes ketonemia, uremia, lactic acidemia, or ingestion of substances such as ethylene glycol, propylene glycol, methanol, salicylates, tylenol, or toluene
  • Also note how the osmolar gap is 15, suggesting ethylene glycol, propylene glycol, or methanol ingestion

Further Workup

  • UA was negative for ketones, blood, or crystals; serum β-hydroxybutyrate negative
  • BUN/Creatinine within normal limits
  • Lactic acid within normal limits
  • Salicylate and toluene levels negative
  • Volatile acid screen was positive for ethylene glycol at 23 mg/dL


  • Fomepizole was initiated
  • Because of severe acidemia, Nephrology was consulted and hemodialysis was initiated to remove ethylene glycol from the body
  • His acidemia resolved after dialysis, his mental status improved in the following days off of sedation, and he was successfully extubated, at which time he admitted to “Antifreeze” ingestion in a suicide attempt
  • He was discharged home after a Psychiatry consult and initiation of SSRI therapy with close outpatient follow-up

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