55-year-old lady with ASA poisoning, dyspnea and altered mental status.

freecme000
Published on Oct 8, 2022
CC -A 55-year-old woman presented to the Emergency Department with tinnitus, vertigo, nausea, vomiting, and weakness.

PMH -She gave a history of excessive use of salicylate for the previous two to three weeks.

EXAM - Afebrile, BP 101/73, HR 95 bpm, RR 22/min, oxygen saturation is 97%. Alert, awake, mild epigastric pain, lungs clear and no focal CNS deficits.

LABS -

TOX SCREEN- Her initial serum salicylate level was significantly increased at 54 mg/dl (upper therapeutic limit, 19.9 mg/dl).

BMP- Na 138 mEq/L, K 2.7mEq/, Cl 102 mEq/L, Co2 12 mEq/L, BUN 18 mg/d, Cr 0.71mg/dl, Ca 7.0 mg/dl, Glucose 115 mg/dl.

VBG showed- pH7.46 (7.33–7.43), pCO2 21mmHg (38–50), pO2 32 mmHg (30–50), Bicarbonate 15 mmol/L (22–30).

ER COURSE -
She clinically improved following treatment with oral activated charcoal, intravenous saline and sodium bicarbonate, and potassium, calcium replacement. Subsequently she developed shortness of breath, hypoxia (O2 sat 87 %, see CXR figure). She was started on Diamox intravenously for management of pulmonary edema and to promote urinary alkalinization.

Over the next few hours, she developed progressive altered mental status with emesis, headache, increasing confusion, progressing to seizures. MRI brain was done (see figure). VS - BP 101/73, HR 90 bpm, RR 24/min.

REPEAT LABS

A repeat VBG showed worsening metabolic acidosis with a pH 7.23 (7.33–7.43), pCO2 18 mmHg (38–50), Bicarbonate 10 mmol/L (22–30).
Her repeat serum salicylate level was decreased at 34 mg/dl, Creatinine 0.95 mg/dl, Glucose 72 mg/dl

NEXT STEP IN MANAGEMENT OF PATIENT IS AS FOLLOWS-

A. INTUBATE AND START HEMODIALYSIS
B. INTUBATE AND START CRRT.
C STOP IV DIAMOX AND START HEMODIALYSIS
D STOP IV DIAMOX, AND GIVE IV GLUCOSE BOLUS, AND START HEMODIALYSIS

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