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An adolescent is brought in intoxicated with history of drinking large amounts of alcohol at a dorm party. He vomited multiple times at the scene and on arrival to the ED. Initial labs and CXR are normal except for an ETOH level of 390. He is protecting his airway, arousable with deep stimulation, and hemodynamically stable, so the decision is to observe him on a monitor while he slowly sobers up, and then reevaluate him for discharge. However, 2 hours later he is requiring 5L O2 by non-rebreather to maintain an O2 saturation of 97%. He does not show significant respiratory distress or apnea, and a venous blood gas does not reveal CO2 retention or significant acidosis.
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March 24, 2020 at 10:59 am
E) None of the above
The patient is likely to have sustained aspiration, which can lead to a chemical pneumonitis, with symptoms appearing in the first hours after aspiration. If the patient is upright, aspiration is commonly into lower lobes, and the right is most common due to its straighter bronchus; however, if the patient was recumbent (as this patient likely was), the posterior segments of upper lobes or superior segments of lower lobes may be involved. Although the patient is at risk of developing aspiration pneumonia, this is unlikely so soon after the aspiration event, and prophylactic antibiotics are not indicated to prevent pneumonia. Fomepizole is not indicated for ethanol ingestion; it is for other toxic alcohols. Ondansetron is not likely to be helpful in this patient who already aspirated. Corticosteroids are controversial in treatment of several chemical pneumonitis or ARDS, but would not be indicated in the beginnings of more mild chemical pneumonitis. Since the patient has risk of progressing to ARDS, he should be admitted to a monitored bed. Treatment is primarily supportive with positive pressure support / ventilation as indicated.