Based on the clinical vignette, it seems like PJ was trying to commit suicide either by benzodiazepine overdose or by consuming antifreeze. It looks like PJ tried to drink antifreeze based on the sweet smell on his breath in the emergency room. The active ingredient in antifreeze is ethylene glycol, which is a sweet-smelling alcohol. If PJ consumed the antifreeze, then that will explain that clinical finding. When ethylene glycol is oxidized by alcohol dehydrogenase (ADH), its metabolites become toxic and cause an anion gap acidosis and profound CNS depression (Fraser 242). Furthermore, these ethylene glycol metabolites can cause kidney failure, optic disc damage, and other end organ failure. The patient will become sedated and have labored breathing could die.
There are two ways to treat ethylene glycol ingestion. First, is to administer ethanol, which will compete with ethylene glycol for the ADH enzyme. The ethanol has better kinetics and will preferentially bind to ADH. Ethylene glycol is relatively non-toxic when in its natural form and will be able to be excreted benignly through the kidneys. The second form of treatment is fomepizole, an antidote to ethylene glycol and methanol poisoning that is administered intravenously. Regarding supporting care, PJ should also be given sodium bicarbonate for the increased anion gap acidosis and be monitored for respiratory collapse. PJ also had an empty bottle of benzodiazepines with him. This type of medication has a high risk of overdose and causes respiratory depression and failure. He should also be given flumazenil, which is a nonspecific competitive antagonist at the BZD receptor and will reverse the effects of a potential benzodiazepine overdose. Ultimately, PJ will need a psychiatric consult once stabilized, to understand why he wanted to commit suicide in the first place.
Works Cited
Fraser, A.D. “Clinical toxicologic implications of ethylene glycol and glycolic acid poisoning.”
Therapeutic Drug Monitoring. 24.2 (2002): 232-238. Print
