Go Back   Professional Soldiers ® > TMC 14 > Medical Pearls Of Wisdom

Reply
 
Thread Tools Display Modes
Old 05-09-2013, 11:27   #16
Sdiver
Area Commander
 
Sdiver's Avatar
 
Join Date: Feb 2004
Location: The Black Hills of SD
Posts: 5,917
Remember, don't kill the messenger.

Here is the Dx ......

Patient was suffering from ASA or Salicylate Toxicity.

Definition of Toxicity

Salicylate toxicity can result from chronic or acute ingestion. Chronic intoxication results from excessive or therapeutic use over a period of 12 hours or longer. Most commonly, this is seen in elderly patients with arthritis or other musculoskeletal problems. Acute intoxication is more likely to be the result of deliberate self-poisoning. Chronic intoxication is seen less frequently and generally has a poorer outcome, because of a low index of suspicion and delay in proper treatment.

In general, the toxic effects of salicylates are seen at serum levels above 30 mg per dL (2.15 mmol per L). Therapeutic levels needed for the anti-inflammatory effects of salicylates range from 15 to 30 mg per dL (1.10 to 2.15 mmol per L). The Food and Drug Administration recommends that the maximum dose of salicylate in a 70-kg person not exceed 3,900 mg in 24 hours for more than ten days.

Pharmacology

Salicylates are weak acids, and thus are rapidly absorbed from the gastrointestinal tract. Peak serum salicylate levels occur within 12 hours of ingestion. Salicylate-induced pylorospasm and the dosage from (effervescent, enteric coated, etc.) can affect the rate of absorption.

Toxic doses of salicylates have a much longer half-life than therapeutic doses. This is due to a shift from first-order to zero-order kinetics as the salicylate metabolic pathways become saturated even at therapeutic levels. When the enzymes are saturated, plasma salicylate concentration rises rapidly, and toxicity occurs.

Clinical Manifestations

Salicylate toxicity should be suspected in any patient with fever, hyperventilation, seizures or coma of uncertain etiology. It is not uncommon for salicylate poisoning to be misdiagnosed initially as diabetic ketoacidosis.

Initial symptoms of salicylate toxicity include tinnitus (followed by hearing loss), vertigo, nausea, vomiting, hyperventilation and agitation. As the serum level rises, metabolic acidosis ensues, resulting in more severe hyperpnea. This is followed by central nervous system deterioration (lethargy, confusion, delirium, convulsions and, eventually, coma). Fever, due to uncoupling of oxidative phosphorylation, is also a common symptom.

Other manifestations of salicylate toxicity include non-cardiogenic pulmonary edema, renal tubular damage, bleeding disorders and hemolysis. The pathophysiology of salicylate damage to the lungs and kidneys is still unclear, but a central factor seems to be a disruption of capillary permeability to protein, producing high concentrations of protein in both pulmonary edema fluid and urine. A similar phenomenon occurs in cerebral membranes and may produce cerebral edema.

INITIAL TREATMENT

As with any acutely ill patient, initial treatment should focus on establishing an adequate airway, breathing and circulation. The history should include the amount of salicylates ingested, the type of preparation and the exact time of ingestion.

Important initial laboratory tests include an arterial blood gas determination and serum salicylate level, as well as serum sodium, potassium, urea nitrogen and glucose levels and coagulation profile. There are rapid screening tests, such as the ferric chloride test, to detect the presence of salicylic acid in the urine.

IPECAC AND GASTRIC LAVAGE

Gastric emptying should be performed as early as possible by either induced emesis should attemtp to prevent drug absorption by gastric emptying and the use of activated charcoal.

Central to the management of these patients is the use of intravenous fluids and bicarbonate to produce alkaline diuresis and to correct acid-base and electrolyte abnormalities. These patients should be monitored closely and treated aggressively; in some patients, hemodialysis may be necessary.


* Unknown what her labs were.
* Unknown if this was a suicide attempt.
__________________
Non Sibi Sed Suis
_____________________________________________
It's Good To Be Da King !!!! Just ask NDD !!!!
Sdiver is offline   Reply With Quote
Old 05-09-2013, 11:43   #17
Sacamuelas
JAWBREAKER
 
Sacamuelas's Avatar
 
Join Date: Jan 2004
Location: Gulf coast
Posts: 1,905
Thumbs up

Classic presentation of a drug overdose/interaction case.
Sacamuelas is offline   Reply With Quote
Old 05-09-2013, 11:44   #18
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
That was fun. Let's do it again.
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Old 05-09-2013, 12:52   #19
Sdiver
Area Commander
 
Sdiver's Avatar
 
Join Date: Feb 2004
Location: The Black Hills of SD
Posts: 5,917
Quote:
Originally Posted by DocIllinois View Post
See, Trapper, metabolic alkalosis wasn't TOO far off.
When you posted your Dx right away as alkalosis, I was thinking, "Oh wow, this Doc is good." But then you second guessed yourself and then I was like, "YES, we've got something here."

Quote:
I agree- one more, please.

How about letting us ask the Pt a few questions next time, Sdiver? Just pretend you're a 44 y.o. woman in pain.
Sure. Be more than happy to.
In fact, let me see if I can embed a video for everyone.
__________________
Non Sibi Sed Suis
_____________________________________________
It's Good To Be Da King !!!! Just ask NDD !!!!
Sdiver is offline   Reply With Quote
Old 05-09-2013, 21:26   #20
UWOA (RIP)
Quiet Professional
 
UWOA (RIP)'s Avatar
 
Join Date: Jan 2013
Location: You can't get here from there; you have to go someplace else first.
Posts: 967
Whoopie!
__________________
No one knows whether you're a genius or an idiot until you open your mouth and remove all doubt.

Don't know where I'm goin', but there's no use in bein' late.
I've never been lost. I've been a mite confused at times, but never lost.
I'm not lost! I know where I am; I just don't know where everybody else is.
UWOA (RIP) is offline   Reply With Quote
Old 05-10-2013, 00:23   #21
Patriot007
Guerrilla
 
Join Date: Nov 2006
Location: Free Pennsylvania
Posts: 138
Great case and good overview Sdiver!

To clarify treatment as far as recent literature is concerned:

Controversial but generally, induced vomiting is no longer recommended due to the risk of aspiration.

Gastric lavage and aspiration ("stomach pumping") is only recommended if the ingestion has been within 1 hour of ingestion. Typically use a 28 French Ewald tube(Big honkin' tube!) that can only go down if patient is intubated- aspirate flush with saline then aspirate for pill fragments if you get pill fragments rinse and repeat.

Charcoal is nasty thick stuff and due to risk of dangerous aspiration is only recommended if patient has normal neurologic function or is intubated.

In the field it is important to gather evidence of co-ingestions,OTC or prescription bottles, and as much bystander info as possible so that doses can be estimated.

Lastly- aspirin in one of the drugs that can be dialyzed so mistriage to a small department where dialysis will not be possible may cost valuable time. If you have good evidence of a particular overdose discuss with medical control early. They may also give you a contingency treatment plan if the patient decompensates en route in addition to standard ACLS.

Last edited by Patriot007; 05-10-2013 at 00:46.
Patriot007 is offline   Reply With Quote
Reply


Currently Active Users Viewing This Thread: 1 (0 members and 1 guests)
 
Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is Off
HTML code is Off

Forum Jump



All times are GMT -6. The time now is 23:50.



Copyright 2004-2022 by Professional Soldiers ®
Site Designed, Maintained, & Hosted by Hilliker Technologies