57 yo F brought in by brother-in-law for purported suicide attempt. He tells me she's done things in the past, but nothing serious, and that he believes she is just trying to get attention. Pt is somnolent but arousable, I do my quick standard psych H&P, patient reports that she drank 10 ounces of windshield wiper fluid approximately 12 hours ago with the intent of killing herself. She is mildly tachypneic and diaphoretic, so the first the thing we do is order an ABG:
pH 7.06, HCO3 6, and anion gap of 32
ELEVATED ANION GAP ACIDOSIS!!
Remember MUDPILES?
M-methanol
U-uremia
D-DKA
P-propylene glycol
I-infection/isoniazid/iron tox/isopropyl alcohol
L-lactic acidosis
E-ethylene glycol
S-salycylism
Re-evaluation of patient showed decreasing GCS and increased WOB, so we moved her to CC room and intubated her. Patient was started on fomepizole drip (I wanted to started pouring whiskey down her OG tube but Erik wouldn't let me) for presumed toxic alcohol toxicity, vascular surgery was called to place catheter for emergency HD, and nephrology was emergently consulted.
Toxic alcohol levels showed an initial methanol level of 145 mg/dL; no ethylene glycol or isopropyl alcohol detected.
Nephrology recommended adding bicarb drip, and within a couple hours hemodialysis had begun. After 3 hrs of HD, methanol levels were down to 68, pH increased to 7.50, and the anion gap was closing. Pt then went to ICU.
She underwent a total of 12 hours of HD. On day 2 of hospitalization, methanol level was <25, so fomepizole and HD were dc'ed. Pt was shortly therafter extubated, and transferred the next day to psych floor. Interestingly, she never developed any opthalmologic complications.
One final footnote: Before she crunked and got tubed, she was trying to remember the brand of wiper fluid she'd guzzled. All she could remember that it had the word "Blast" in it. After some internet research, I read that there was indeed a company based out of Minnesota that made a wiper fluid called "PowerBlast." Interestingly, they were currently being sued by another windshield wiper producer for "watering down" their product, ie, using less methanol, to save on manufacturing cost. I found it interesting that perhaps by working to improve their bottom line, the company had inadvertently made their product less toxic, and as such perhaps prevented this particular patient's demise (although who knows the M&M that resulted from spinouts out on icy roads by drivers unable to see out of frozen, wiper-fluid-encrusted windshields).