The Body After Drinking A Snowglobe (High Anion Gap Metabolic Acidosis)

Heme Review

Video version of episode: https://www.youtube.com/watch?v=elzijduKNS8

Chubbyemu case: https://youtu.be/UrbylXMU8Mw

Most snowglobes are just made of water, but some can contain ethylene glycol. Most of those usually don't contain enough ethylene glycol to cause damage, but keep the word "usually" in mind. A homemade snowglobe can contain concentrations of anything, which is what happened in this case.

Ethylene glycol can cause a profound high anion gap metabolic acidosis, and we'll explain the science, chemistry and physiology behind that in this episode.

References:

Delayed ethylene glycol presenting with abdominal pain and multiple cranial and peripheral neuropathies: a case report. Journal of Medical Case Reports volume 4, Article number: 220 (2010).

Multiple Cranial Nerve Deficits After Ethylene Glycol. Ann Emerg Med. 1991 Feb;20(2):208-10. https://pubmed.ncbi.nlm.nih.gov/1996809/

Antidotes OH that form toxic metabolites. Br J Clin Pharmacol. 2016 Mar; 81(3): 505–515. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4767193/

Toxic Alcohols. N Engl J Med 2018; 378:270-280. https://www.nejm.org/doi/full/10.1056/NEJMra1615295

Ethylene glycol ingestion masked by concomitant ethanol ingestion. Case Reports 2012;2012:bcr1220115326. https://casereports.bmj.com/content/2012/bcr.12.2011.5326

Challenges in the Diagnosis of Ethylene Glycol Poisoning. Ann Clin Biochem. 2014 Mar;51(pt2):167-78. https://pubmed.ncbi.nlm.nih.gov/24215789/

Emmett M, Narins RG. Clinical use of the anion gap. Medicine (Baltimore) 1977;56:38-54.

Uribarri J, Oh MS, Carroll HJ. D-lactic acidosis: a review of clinical presentation, biochemical features, and pathophysiologic mechanisms. Medicine (Baltimore) 1998;77:73-82.

Judge BS. Metabolic acidosis: differentiating the causes in the poisoned patient. Med Clin North Am 2005;89:1107-1124.

Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786-1795. https://www.nejm.org/doi/full/10.1056/NEJMra020617

A 49 Year Old Man With Obtundation Followed By Agitation And Acidosis. N Engl J Med 2015; 372:465-473. https://www.nejm.org/doi/full/10.1056/NEJMcpc1410940

Integration of Acid-Base And Electrolyte Disorders. N Engl J Med 2014; 371:1821-1831. https://www.nejm.org/doi/full/10.1056/NEJMra1215672

Calcium Kidney Stones. N Engl J Med 2010; 363:954-963. https://www.nejm.org/doi/full/10.1056/NEJMcp1001011