Today’s topic will be for the people who used this 3-day weekend for a bender:
Alcohol Ketoacidosis (AKA)
Someone who has been on a bender and shows up to your ED after two days of vomiting, has a low bicarb, elevated anion gap, elevated lactate, urine ketones, and an elevated BHB level...probably has AKA.
Alcoholic ketoacidosis (AKA) is a starvation state in an alcoholic or binge drinker
Alcohol + No Food + Dehydration = AKA
Most often associated with acute cessation of alcohol consumption after chronic alcohol abuse
Can also be associated with first-time alcohol binge
one of the causes of anion-gap metabolic acidosis
episode of heavy drinking followed by vomiting and an acute decrease in alcohol consumption
N/V, nonspecific abdominal pain
can have associated gastritis or pancreatitis
normal mental status, but if patient is altered, look for toxic alcohol ingestion, postictal states from withdrawal seizures, or occult head injury
exam with acetone odor on breath
tachypnea (Kussmaul respiration), tachycardia, and signs of dehydration
Nicotinamide adenine dinucleotide (NAD, or “Needs Additional Dextrose”) is depleted by ethanol metabolism, leading to inhibition of the Kreb’s cycle (or aerobic metabolism) in favor of ketone formation, depletion of glycogen stores, and suppression of insulin secretion
low, normal, or slightly elevated glucose
binge-drinking that ends in N/V and decreased intake
wide AG metabolic acidosis, especially one without an alternative diagnosis
(+) serum ketones
can have associated hypophosphatemia, hyponatremia, and hypokalemia
Sugar and water!
Glucose stimulates insulin production, which stops lipolysis and halts further ketone formation. Glucose also increases oxidation of NADH to NAD, thereby further stopping ketone production.
Start with 5% dextrose in NS. Once fluid and electrolyte losses are replaced, change fluids to 5% dextrose in 1/2 NS until oral intake is assured.
Give 100 mg thiamine (facilitates Krebs cycle)
Repeat Chem7 to see if bicarb improving. If it’s not, consider ethylene glycol or methanol poisoning. This is the time for fomepizole and a call to your local toxicologist or poison center!
Discharge if tolerating PO!