Review Question - QID 109336

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Approach to Overdose/Poisoning QID: 109336 (M2.PH.17.4800)

QID 109336 (Type "109336" in App Search)

A 23-year-old male is brought into the emergency department by his girlfriend following an argument. The patient’s girlfriend claims that she threatened to break up with him. He then called her saying he was going to kill himself. When she arrived at the patient’s home, she found him lying on the couch with empty alcohol bottles and multiple pill containers. The patient reports he does not remember everything he took, but says he ingested many pills about four hours ago. The patient’s temperature is 99°F (37.2°C), blood pressure is 110/68 mmHg, pulse is 88/min, and respirations are 25/min with an oxygen saturation of 98% O2 on room air. An arterial blood gas (ABG) is obtained, with results shown below:

pH: 7.47
pO2: 94 mmHg
pCO2: 24 mmHg
HCO3-: 22 mEq/L

The patient is placed into observation. In the morning, the patient appears agitated. His girlfriend says he keeps grabbing his head, yelling about non-stop ringing in his ears. Labs and a repeat ABG shows:

pH: 7.30
pO2: 90 mmHg
pCO2: 22 mmHg
HCO3-: 9 mEq/L
Na+: 144 mEq/L
Cl-: 98 mEq/L
K+: 3.6 mEq/L
BUN: 18 mg/dL
Glucose: 100 mg/dL
Creatinine: 1.4 mg/dL

Which of the following is the best next step in management?

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Acetazolamide

17%

7/42

Activated charcoal

2/42

N-acetylcysteine

14%

6/42

IV haloperidol

0/42

IV sodium bicarbonate

62%

26/42

Select Answer to see Preferred Response

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This patient is presenting with a tinnitus and respiratory alkalosis then anion gap metabolic acidosis following a suicide attempt, suggesting aspirin toxicity. This should be managed with IV sodium bicarbonate.

Aspirin or salicylate toxicity often presents with tinnitus and fever. An ABG may exhibit a respiratory alkalosis due to activation of the medulla’s respiratory center. The ABG may then progress to an anion gap metabolic acidosis caused by uncoupling phosphorylation in the mitochondria, though the pH may only be slightly acidic because of the opposing mechanisms. The goal of management is alkalinization with IV sodium bicarbonate. If the patient develops somnolence, pulmonary edema, or severe academia (pH <7.2), hemodialysis may be indicated.

Incorrect Answers:
Answer 1: Acetazolamide is contraindicated in the management of salicylate toxicity. Although acetazolamide alkalinizes the urine and increases salicylate excretion, it does so by reducing bicarbonate reabsorption, which lowers the arterial pH. This can worsen acidemia and promote the movement of salicylate into the brain.

Answer 2: Activated charcoal can absorb aspirin and can be given to alert and non-combative patients within two hours of aspirin ingestion. It should be avoided in patients with altered mental status or increasing somnolence, who are at risk for an unprotected airway.

Answer 3: N-acetylcysteine is indicated in acute ingestions of acetaminophen not aspirin.

Answer 4: IV haloperidol can be used in cases of severely violent patients requiring rapid sedation or agitated patients with a known psychiatric disorder. For patients with agitation related to drug intoxication or drug withdrawal, benzodiazepines are normally used if sedation is needed.

Bullet Summary:
Aspirin toxicity presents with tinnitus and fever and should be managed with IV sodium bicarbonate.

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