Diagnostic Skills Challenge –2016 3rd Quarter Newsletter

41-Year-Old Female with Disorientation & Tachypnea

EMS has transported a 41-year-old woman who they state was found walking down a road totally disoriented and unable to identify herself. A family member arrived and informed the staff that the patient was an avid runner and other than muscle pains related to that activity had made no other complaints about her physical state. VITAL SIGNS: BP=140/70 mm Hg, RADIAL PULSE= 122/minute, RESPIRATORY FREQUENCY=31/minute (with no signs of increased work of breathing), and her PULSE-OX=96% (FI02=.21).

Her general physical exam was essentially negative except for the confusion, and the tachypnea. Her blood glucose level (meter) was normal. URINALYSIS: S/G=1.022, pH=5.54, 3+ ketones, and 3+ protein. 12-lead electrogram= normal sinus tachycardia. An APLateral chest radiograph showed scattered patchy infiltrates bilaterally. The patient was admitted with a diagnosis of acute pneumonia and I.V. antibiotics were started.

Further Assessment

After admission, an ABG was obtained due to the continuing tachypnea. The results were: pH-7.47, paC02-25 mm Hg., pa02-61 mm Hg. (FIO2=21%). The nursing staff noted the odor of “wintergreen” on the patient. Based on the above, blood was sent to the lab to obtain a salicylate level which came back at 66 mg/dl. The patient reported that she had been using large amounts of topical liniment and P.O. aspirin over the last 4 days to manage back and lower extremity pain. 

QUESTION 1:

What is your diagnosis?

A. Acute salicylate intoxication
B. Bilateral pneumonia
C. Spontaneous pneumothorax
D. Severe anxiety reaction

QUESTION 2:

What is the best course of treatment for this patient?

A. Antibiotic therapy
B. Inhaled bronchodilator
C. Emergency hemodialysis
D. A chest tube

BONUS QUESTIONS:

1. What is the primary blood gas derangement seen with acute salicylate intoxication?

A. Hypercarbia with metabolic alkalosis
B. Hypercarbia with no metabolic changes
C. Mixed respiratory alkalosis with metabolic acidosis
D. Severe hyperoxia

2. It is important to assess patients presenting with salicylate intoxication considering whether it is acute or chronic.

A. True
B. False

3. Sodium bicarbonate therapy is safe and always recommended.

A. True
B. False

4. Other than measuring serum salicylate levels, what laboratory result should cause a practitioner to consider salicylate intoxication?

A. Elevated anion gap
B. Highly elevated serum calcium
C. Highly elevated serum glucose level
D. None of the above

5. Aspirin is the only substance which produces clinical salicylate toxicity.

A. True
B. False

BONUS FACTS ABOUT ACUTE SALICYLATE INTOXICATION

• According to the CDC, products containing salicylates account for about 15% of annual analgesic-related death each year.
• Aspirin is not the only problematic agent. Methyl salicylate compounds used topically cause unintentional exposure.
• Pepto-Bismol has 8.7 mg of salicylate per ml.
• Salicylates have wide-spread effects on the human body. Tinnitus, gastric disorders, hyperthermia, anion-gap metabolic acidosis, non-cardiogenic pulmonary edema, cerebral edema, seizures and death have been reported.
• The most common diagnosis pathway is the presence of an elevated serum salicylate level. It is important to obtain clear, accurate history which would lead to the possibility. Also, chronic toxicity may show lower than expected level elevation, making the assessment of the patient’s symptoms essential in determining the level of intoxication.
• Initial management is airway/ventilation/I.V. access.
• Aspirin is well bound by activated charcoal.
• Ipecac is NO longer recommended.
• Some consider serum alkalization with NaHC03 (guard against severe alkalemia).
• Hemodialysis may be considered in cases where there is: persistent severe electrolyte and/or acid-base disturbances failing to respond to aggressive therapy, cerebral or pulmonary edema, progressive clinical decline. Some texts suggest that dialysis should occur at serum salicylate levels >90 mg/dL (acute) and >60 mg/dL (chronic). Most experts agree dialysis should be considered in very ill patients.