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Unexplained metabolic acidosis

A man in his 20s was found to be unresponsive after experiencing headache and vomiting for two days. Hismedical history includeddepression,paracetamol (acetaminophen) overdose on several occasions, and an episode of unexplained encephalopathy five months earlier. He experienced two generalised tonic-clonic seizures during initial assessment in the emergencydepartment.Clinical examination revealed a Glasgow coma scale score of 3/15, with global hypotonia, areflexia, and size 6 pupils that were unresponsive to light. A systematicABCDEapproachwas taken,witha focus on securing the airway because of the patient’s decreased level of consciousness.1 Arterial blood gas test results showed a metabolic acidosis with raised levels of lactate. Table 1 summarises the patient’s laboratory test results on presentation to the emergency department.