Download Managing Acute Salicylate Overdose: Repeated ASA Levels and Actions and more Lecture notes Toxicology in PDF only on Docsity!
Acute Aspirin Overdose Author: Shawn M. Varney
Reviewers: Joseph Yanta
Target Audience: Emergency Medicine Residents, Medical Students
Primary Learning Objectives:
- Recognize signs and symptoms of aspirin (ASA)/salicylate toxicity
- Perform appropriate gastric decontamination/enhanced elimination
- Describe technique for alkalinizing urine
- Discuss potential complications of mechanical ventilation
- Recognize indications for hemodialysis in ASA overdose
- Order appropriate laboratory and radiology studies in ASA overdose
Secondary Learning Objectives: detailed technical/behavioral goals, didactic points
- Obtain psychiatric evaluation for suicidal patients
- Develop independent differential diagnosis in setting of leading information from RN
- Describe importance of potassium replacement during urinary alkalinization
- Describe role of repeated ASA levels
- Describe role of WBI and MDAC in gastric decontamination of ASA ingestion
Critical actions checklist:
- Perform gastric decontamination with AC – (May consider multi-dose activated charcoal. WBI is optional.)
- Order ASA level and basic metabolic panel; (then serial ASA levels, potassium, bicarbonate, creatinine)
- Volume resuscitate with NS
- Alkalinize urine and replace potassium
- Consult Poison Center and Nephrology to arrange for dialysis
- Consider potential problems with mechanical ventilation
Environment:
- Room Set Up – ED non-critical care area a. Manikin Set Up – Mid or high fidelity simulator, simulated sweat b. Props – Standard ED equipment
- Distractors – ED noise, ED nurse #2 who insists this patient needs to “sleep it off”
For Examiner Only
CASE SUMMARY
SYNOPSIS OF HISTORY/ Scenario Background
The setting is an urban emergency department.
Patient is a 40-year-old female with a history of anxiety, ADHD, and polysubstance abuse brought to the emergency department by EMS for altered mental status, agitation, and rapid respirations. The patient’s father said she is always anxious, has recently been depressed, but is not aware of any suicidal ideations.
PMHx: anxiety, ADHD, and polysubstance abuse PSHx: cholecystectomy Medications: Alprazolam, Buspirone, Adderall, Sertraline Allergies: NKDA SocHx: Binge EtOH use; tobacco, marijuana, prescription opioids; lives alone in own apartment
[Patient has an aspirin overdose, is agitated, and is intoxicated with alcohol. Given her psychiatric history, emotional outbursts, and evidence of alcohol, she is triaged to the behavioral health evaluation area.]
SYNOPSIS OF PHYSICAL
Patient is initially anxious, tachycardic, tachypneic. Airway is intact. Neurologic exam is non focal. She is agitated. Mental status is altered – moaning/ cursing, and she appears intoxicated and anxious. Skin is diaphoretic. She has vomit on chest.
Critical Actions Checklist 1
Resident Name
Case Description
Skills measured
Core competencies: PC Patient care, MK Medical knowledge, IC Interpersonal and communication skills P Professionalism, PB Practice-based learning and improvement SB Systems-based practice
Very Unacceptable Unacceptable Acceptable
Very Acceptable
Data Acquisition (D) PC MK I 1 2 3 4 5 6 7 8
Problem Solving (S) PC MK PB 1 2 3 4 5 6 7 8
Patient Management (M) PC MK IC P PB SB 1 2 3 4 5 6 7 8
Resource Utilization (R) PC PB SB 1 2 3 4 5 6 7 8
Health Care Provided (H) PC SB 1 2 3 4 5 6 7 8
Interpersonal Relations (I) IC P 1 2 3 4 5 6 7 8
Comprehension of Pathophysiology (P) MK PB
1 2 3 4 5 6 7 8
Clinical Competence (C) PC MK IC P PB SB 1 2 3 4 5 6 7 8
Critical Actions
Yes No (^) Comments: Perform GI decontamination Order appropriate labs Initiate volume resuscitation Alkalinize urine Consult poison center Arrange for dialysis Yes No Exercise caution with intubation Dangerous actions
(^1) Modified ABEM Oral Certification Examination checklist and scoresheet
For Examiner Only
HISTORY
You are called to see a new patient (40-year-old female) in the Psychiatric Treatment area of the emergency department. You see a pale, diaphoretic female who is altered.
Onset of Symptoms: Today
Background Info: 40-year-old female is anxious, depressed, agitated, with labile emotions, and not answering questions clearly. The patient’s father said he found her earlier today confused and breathing rapidly. She didn’t improve, so he called 911.
Additional History
From EMS: If asked about the scene in the apartment they will describe a cluttered, small apartment. There were a few empty beer cans and a large empty bottle of aspirin. She vomited during transport.
From Father: He states that the patient has been anxious and depressed. She recently broke up with her boyfriend and has been under stress.
Chief Complaint: Anxiety
Past Medical Hx: Anxiety, ADHD, and polysubstance abuse
Past Surgical Hx: Cholecystectomy
Habits: Smoking: Occasional ETOH: Binge drinking Drugs: Marijuana, prescription opioids
Family Med Hx: Hypertension, diabetes
Social Hx: Marital Status: Single Children: None Education: High School Employment: Unemployed
ROS: Patient is unable to answer.
PHYSICAL EXAM
General Appearance: Pale, diaphoretic female. Unresponsive.
Vital Signs: BP: 90/54 mmHg P: 130/minute R: 36/minute T: 38C (100.4F) Pox: 90%
Head: Normal
Eyes: PERRLA, pupils 2 mm B
Ears: TM’s normal. Decreased hearing
Mouth : Smells of alcohol, no trauma, dry mucous membranes and lips
Neck: No tenderness or deformity on exam, full range of motion
Skin: Moist skin/sweaty, no rashes, warm
Chest: Increased respiratory rate without any signs of distress (no retractions)
Lungs: Clear, equal bilaterally with rapid, deep breaths but labored
Heart: Tachycardic, S1 S2, no murmurs
Back: Normal
Abdomen: Soft, nontender, no signs of trauma, no rebound/guarding, decreased bowel sounds
Extremities: No signs of trauma, no edema, pulses are present
Genital: Digital vaginal exam negative for retained foreign body
Rectal: Normal tone, guaiac negative
Neurological: Non-focal exam, no clonus
Mental Status: Unable to assess due to AMS
Required Actions
∞ Further resuscitation with IV NS 1-2 L ∞ May order portable CXR and KUB (signs of pulmonary edema, gastric concretions, or other acute pathology) ∞ May order non-contrast head CT but cannot obtain until patient is more stable ∞ May place a Foley catheter (drain 300 mL of urine)
CASE CONTINUATION
∞ SBP remains in 90s ∞ Initial ASA level is 86 mg/dL
Branch Point
Required Actions
Branch Point
Required Actions
Branch Point
∞ IF ANOTHER 1-2L NS NOT GIVEN ABOVE, BP drops to 60’s, and patient seizes.
∞ Administer 2-3 50-mL ampules of 8.4% NaHCO 3 IV bolus ∞ Mix/order a NaHCO 3 drip (3 ampules of 8.4% NaHCO 3 in 1L D 5 W) and run at 250mL/hr ∞ Add 20-40 mEq/L KCl to NaHCO 3 infusion
- Pt remains symptomatic during bicarbonate infusion.
∞ Pt continues to be altered, acidotic, tachypneic. Discussion of impending respiratory failure and managing the airway ∞ While preparing for RSI, the ASA level returns = 138 mg/dL ∞ VBG at that time shows pH 7.39, pCO 2 20 mm Hg, paO 2 39 mm Hg, base deficit 11 ∞ Postpone intubation until acidosis is corrected somewhat
∞ IF TEAM PROCEEDS WITH INTUBATION WITHOUT CORRECTING ACIDOSIS
(administering bicarb bolus 1-2 amps), they will successfully place the endotracheal tube, but the patient will subsequently seize and die
∞ Intubate the patient using RSI. Maximize minute ventilation (e.g., TV 500, RR 30, PEEP 5) ∞ Call the Poison Center ∞ Consult Medical Toxicology ∞ Order/obtain serial ASA levels, BMP (for K, HCO 3 , cre) every 1-2 hours initially
∞ IF SERIAL LEVELS ARE NOT CHECKED, patient seizes and dies.
For Examiner Only
STIMULUS INVENTORY
#1 CBC
#2 BMP/LFTs
#3 U/A
#4 VBG
#5 Cardiac Enzymes
#6 Toxicology Labs
#7 CXR
#8 CT Head
#9 Abdominal XR
#10 Repeat Toxicology Labs
#11 Repeat BMP
#12 ECG
#13 Debriefing materials
For Examiner Only LAB DATA & IMAGING RESULTS
Stimulus #1 Stimulus # Complete Blood Count (CBC) Arterial Blood Gas WBC 14,500/mm 3 pH 7. Hemoglobin 13.2 g/dL pCO 2 20 mm Hg Hematocrit 40% pO 2 101 mm Hg Platelets 239,000/mm 3 HCO 3 14 mEq/L Differential SaO 2 94% (FiO 2 =0.21) PMNLs 45% Lymphocytes 55% Stimulus # Monocytes 2% Cardiac enzymes Eosinophils 1% Troponin 0.025 ng/mL Bands 1% Stimulus # Stimulus #2 Toxicology Basic Metabolic Profile (BMP) Salicylate 85 mg/dL Sodium 145 mEq/L Acetaminophen Undetectable Potassium 3.6 mEq/L Ethanol 112 mg/dL Chloride 109 mEq/L Bicarbonate 16 mEq/L Stimulus # Glucose 73 mg/dL CXR: normal BUN 17 mg/dL Creatinine 1.1 mg/dL Stimulus # Head CT: normal Stimulus # Liver Function Tests Stimulus # AST 49 U/L AXR: normal ALT 32 U/L Alk Phos 110 U/L Stimulus # Total Bilirubin 1.2 mg/dL Repeat toxicology Direct Bilirubin 0.2 mg/dL Salicylate 141 mg/dL Albumin 4 mg/dL Protein 7 mg/dL Stimulus # Repeat Basic Metabolic Panel Stimulus #4 Sodium 146 mEq/L Urinalysis Potassium 3.2 mEq/L Color Yellow Chloride 111 mEq/L Specific gravity 1.017 Bicarbonate 12 mEq/L Glucose Negative Glucose 68 mg/dL Protein Negative BUN 12 mg/dL Ketones Trace Creatinine 1.0 mg/dL Leuk. esterase Negative Nitrite Negative Stimulus # WBC 3/hpf ECG RBC 2/hpf Sinus tachycardia. No T-wave or ST- segment elevation; no RV strain
Stimulus # Basic Metabolic Profile (BMP) Sodium 145 mEq/L Potassium 3.6 mEq/L Chloride 109 mEq/L Bicarbonate 16 mEq/L Glucose 73 mg/dL BUN 17 mg/dL Creatinine 1.1 mg/dL
Stimulus # Liver Function Tests AST 49 U/L ALT 32 U/L Alk Phos 110 U/L Total Bilirubin 1.2 mg/dL Direct Bilirubin 0.2 mg/dL Albumin 4 mg/dL Protein 7 mg/dL
Stimulus # Cardiac enzymes Troponin 0.025 ng/mL
Stimulus # Toxicology Salicylate 85 mg/dL Acetaminophen Undetectable Ethanol 112 mg/dL
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