patient name; age · web viewpatient is david lopez who is a 22 year old male. he was found at the...

David Lopez; 22 5/04/1988

Author: Steve McLaughlin, MD Reviewer: Deepi Goyal

Case Title: Acute Aspirin Overdose

Target Audience: Emergency Medicine Residents

Primary Learning Objectives:1. Recognize signs and symptoms of ASA toxicity2. Perform appropriate gastric decontamination3. Describe technique for alkalinizing urine4. Recognize indications for hemodialysis in ASA overdose5. Order appropriate laboratory and radiology studies in ASA overdose

Secondary Learning Objectives: detailed technical goals, behavioral goals, didactic points1. Obtain psychiatric evaluation for suicidal patients2. Develop independent differential diagnosis in setting of leading information from RN3. Describe importance of K replacement during urinary alkalinization4. Describe role of repeated ASA levels5. Describe role of WBI and MDAC in gastric decontamination of ASA ingestion

Critical actions checklist:1. Perform gastric decontamination with AC – (Lavage or WBI are optional)2. Order ASA level and Chemistry panel3. Volume resuscitate with NS4. Alkalinize urine using appropriate formula including K replacement5. Consult Poison Control Center and arrange for dialysis6. Obtain head CT to evaluate for trauma

Environment:1. Room Set Up – ED non-critical care area

a. Manikin Set Up – Mid or high fidelity simulator, simulated sweat, abrasion to forehead, vomit on chest

b. Props – Standard ED equipment2. Distracters – ED noise, ED nurse #2 who insists this patient needs to “sleep it off”

Actors:1. Physician (played by resident learner)2. Nurse #1 (can be learner or confederate)3. Nurse #2 (confederate/insists patient needs to “sleep it off”)4. ED technician (optional, can be learner)5. Patient’s friend (confederate/provides history)

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For Examiner Only

Author: Steve McLaughlin, MD Reviewer: Deepi Goyal

Case Title: Acute Aspirin Overdose

CASE SUMMARY

CORE CONTENT AREA

Toxicology

SYNOPSIS OF HISTORY/ Scenario Background

The setting is an urban emergency department.

Patient is David Lopez who is a 22 year old male. He was found at the bottom of the stairs leading up to his apartment by a friend. He has recently been depressed and has been drinking alcohol. The friend is not aware of any suicidal ideations.

PMHx: AppendectomyMedications: NoneAllergies: NKDASocHx: Binge ETOH use, occasional tobacco, lives alone in apartment

[Patient is intoxicated and has an aspirin overdose. He fell down the stairs due to intoxication but has no significant injuries.]

SYNOPSIS OF PHYSICAL

Patient is initially tachycardic and tachypneic.Airway is intact. C-collar in place.Abrasion to his forehead.Neurologic exam is non focal. Mental status is altered – moaning/cursing/appears intoxicated.Skin is diaphoretic.He has vomited and has vomit on chest.

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For Examiner Only

CRITICAL ACTIONS

1. GI Decontamination

Perform gastric decontamination with activated charcoal (Lavage or whole bowel irrigation are optional)

Cueing Guideline: Nurse can ask if the doctor would like to place and NGT. Nurse can ask if the doctor would like anything done with the NGT.

2. Appropriate Labs

Order salicylate level, acetaminophen level and chemistry panel

Cueing Guideline: The nurse or unit secretary can ask the doctor if they would like any labs or any levels on the patient.

3. Volume Resuscitation

Give 1 to 2 liters of NS for volume resuscitation.

Cueing Guideline: The nurse may say “we have a line in place would you like any fluids?” If that does not work the nurse can point out the tachycardia and ask if the doctor would like to do anything. If not done the patient will become more tachycardic and may drop blood pressure to 90/53.

4. Alkalinize Urine

Alkalinize urine using appropriate formula including K replacement

Cueing Guideline: Patient will have worsening acidosis and dropped K (see second chemistry panel) if not treated. Even if the patient is treated the ASA will continue to climb and the patient will need dialysis.Ok to ask for details such as rate and target urine pH.

5. Poison Control Center (PCC) and Dialysis

Consult PCC and arrange for dialysis

Cueing Guideline: The PCC can call the ED and ask for the doctor if the resident does not call. If the resident does not consider dialysis then the actor playing the PCC on the phone can suggest dialysis for patient with major SxS and level over 140 which is climbing.

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6. Critical Action

Obtain Head CT

Cueing Guideline: Nurse can ask “Do you want to go to CT before we go up to the floor?” Nurse can say “Are you worried about trauma with his fall?”

SCORING GUIDELINES1. Full credit given for placing NGT and giving 50 grams of AC with cathartic. Full credit also

given if lavage done in addition to AC. Full credit also given if WBI done in addition to AC. Partial credit for AC in wrong dose or without cathartic. No credit if attempt to have this drowsy patient drink AC. No credit if AC not given.

2. Full credit for electrolytes, glucose, BUN, Cr and ASA and APAP levels. No credit if any or all of these critical labs are omitted.

3. Full credit for volume resuscitation with any amount between 1 and 2 L. LR is an acceptable alternative. Partial credit if volume of resuscitation is between 500 cc and I L. No credit if only maintenance fluids given, if less than 500 cc of if initial resuscitation fluid is no NS or LR.

4. Full credit if: Single IV bolus of NaHCO 3 at 1-2 mEq/kg. Follow this with a constant infusion of D5W with NaHCO 3 100-150 mEq/L and KCl 20-40 mEq/L at 1.5-2.5 mL/kg/h to produce a urine flow of 0.5-1 mL/kg/h. Closely monitor the serum electrolytes and urine pH, and maintain the urinary pH between 7.5-8. Partial credit for other formulas or if missing some details. No credit if potassium is omitted or no drip started or no attempt to alkalinize.

5. Full credit for calling the PCC and providing patient information. Partial credit for asking for a “toxicology consult.” No credit if participant refuses to talk to PCC on phone. Full credit for calling the nephrologist and describing indications for dialysis in ASA OD. Partial credit for asking for a nephrology consult or if unable to give indications. No credit if participant refuses to follow PCC advice.

6. Full credit for ordering head CT. Partial credit if CT done with prompting. No credit if refuses CT even after prompting.

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For Examiner Only

HISTORY

Onset of Symptoms: Today

Background Info: “Mr. Lopez has been drinking all evening. It looks like he fell down the stairs at his apartment. He was found by his friend who called 911. His friend states that he has been depressed recently and drinking a lot of alcohol.”

Additional History

From EMS: If asked about the scene in the apartment they will describe a cluttered, small apartment. There were multiple empty bottles of “Jack Daniels” as well as an empty bottle of penicillin, a half empty bottle of “Vicodin” and a large half empty bottle of aspirin. He has been vomiting during transport.

From Friend: He states that Mr. Lopez has been very depressed. He recently broke up with his girlfriend.

Chief Complaint: Fall

Past Medical Hx: None

Past Surgical Hx: Appendectomy

Habits: Smoking: OccasionalETOH: Heavy binge drinkingDrugs: None

Family Med Hx: Unknown

Social Hx: Marital Status: SingleChildren: NoneEducation: High SchoolEmployment: Unemployed food service worker

ROS: Patient is unable to answer.

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For Examiner Only

PHYSICAL EXAM

Patient Name: David Lopez Age & Sex: 22 year old male

General Appearance: Well-developed, well-nourished male in moderate distress. Vomit noted on front of clothing.

Vital Signs: BP: 108/64 P: 131 R: 40 T : 38.0

Head: Abrasion/contusion to forehead.

Eyes: PERRLA, pupils 4 mm B, lateral nystagmus

Ears: TM’s are normal

Mouth: Smells of ETOH beverages, no trauma

Neck: C-collar and on a long spine board. No tenderness or deformity on exam.

Skin: Moist skin/slightly sweaty, no rashes

Chest: Increased respiratory rate without any signs of distress (no retractions, etc)

Lungs: Clear and equal

Heart: Tachycardic, S1S2, no murmurs

Back: Normal

Abdomen: Mild LUQ TTP, no signs of trauma, no rebound, no guarding, decreased bowel sounds

Extremities: No signs of trauma, no edema, pulses are present

Rectal: Normal tone, guiac negative

Neurological: Non focal exam

Mental Status: Patient is drowsy, opens eyes only to pain, confused and slurred speech, he is not oriented. He is not able to provide any history. His airway appears to be intact with preserved gag and cough reflex.

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For Examiner Only

STIMULUS INVENTORY

#1 Emergency Admitting Form

#2 CBC

#3 BMP/LFTs

#4 U/A

#5 ABG

#6 Cardiac Enzymes

#7 Toxicology Labs

#8 CXR

#9 CT Head

#10 CT C-spine

#11 Abdominal XR

#12 Repeat Toxicology Labs

#13 Repeat BMP

#14 ECG

#15 Debriefing materials

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For Examiner Only

LAB DATA & IMAGING RESULTS

Stimulus #2 Stimulus #5Complete Blood Count (CBC) Arterial Blood GasWBC 14,500 /mm3 pH 7.47Hgb 13.2 g/dL pCO2 19 mm HgHct 40 % pO2 123 mm HgPlatelets 239,000 /mm3 HCO3 14Differential O2 Sat 100%

PNM 45%Bands 1% Stimulus #6Lymphs 55% Cardiac EnzymesMonos 2% CK 98 ng/mlEos 1% CKMB 1 ng/ml Troponin 0.025 ng/ml

Stimulus #3 Stimulus #7Basic Metabolic Profile (BMP) ToxicologyNa+ 145 mEq/L Salicylate 86 mg/dlK+ 3.6 mEq/L Acetaminophen Non detectableCO2 16 mEq/L ETOH 112 mg/%Cl- 109 mEq/LGlucose 73 mg/dLBUN 17 mg/dL Diagnostic ImagingCreatinine 1.1 mg/dL

Stimulus #8AST 49 U/L CXR: NormalALT 32 U/LBr 1.2 mg/dl Stimulus #9D-Br 0.2 mg/dl Head CT: NormalALP 110 U/LAlbumin 4.3 U/L Stimulus #10

CT C-Spine NormalStimulus #4Urinalysis (U/A) Stimulus #11Color yellow Abdominal XR NormalSp gravity 1.017Glucose negProtein negKetone traceLeuk. Est. negNitrite negWBC 3/hpfRBC 2/hpf

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For Examiner Only

LAB DATA & IMAGING RESULTS (cont)

Stimulus #12Repeat ToxicologySalicylate 141 mg/dl

Stimulus #13Repeat BMPNa+ 146 mEq/LK+ 3.2 mEq/LCO2 12 mEq/LCl- 111 mEq/LGlucose 68 mg/dLBUN 12 mg/dLCreatinine 1.0 mg/dL

Stimulus #14ECGSinus tachycardia

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Learner Stimulus #1

CORD General HospitalEmergency Admitting Form

Name: David Lopez

Age: 22 years

Sex: Male

Method of Transportation: Ambulance

Person giving information: Friend and EMS

Presenting complaint: Fell down stairs

Background: Mr. Lopez has been drinking all evening. It looks like he fell down the stairs at

his apartment. He was found by his friend who called 911. His friend states that he has been

depressed recently and drinking a lot of alcohol.

Initial Vital Signs BP: 108/64

P: 131

R: 40

T : 38.0

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Learner Stimulus #2

Complete Blood Count (CBC) WBC 14,500 /mm3

Hgb 13.2 g/dLHct 40 %Platelets 239,000 /mm3

DifferentialPNM 45%Bands 1%Lymphs 55%Monos 2%Eos 1%

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Learner Stimulus #3

Basic Metabolic Profile (BMP) Na+ 145 mEq/LK+ 3.6 mEq/LCO2 16 mEq/LCl- 109 mEq/LGlucose 73 mg/dLBUN 17 mg/dLCreatinine 1.1 mg/dL

AST 49 U/LALT 32 U/LBr 1.2 mg/dLD-Br 0.2 mg/dLALP 110 U/LAlbumin 4.3 U/L

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Learner Stimulus #4

Urinalysis (U/A)Color YellowSp gravity 1.017Glucose negProtein negKetone traceLeuk. Est. negNitrite negWBC 3/hpfRBC 2/hpf

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Learner Stimulus #5

Arterial Blood GaspH 7.47pCO2 19pO2 123HCO3 14O2 Sat 100%

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Learner Stimulus #6

Cardiac EnzymesCK 98 ng/mlCKMB 1 ng/mlTroponin I 0.025 ng/ml

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Learner Stimulus #7

ToxicologySalicylate 86 mg/dLAcetaminophen Non detectableETOH 112 mg/%

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Learner Stimulus #8

CXR Normal

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Learner Stimulus #9

Head CT Normal

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Learner Stimulus #10

C-spine CT Normal

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Abdominal XR Normal

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Repeat ToxicologySalicylate 141 mg/dL

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Repeat Basic Metabolic Profile (BMP)Na+ 146 mEq/LK+ 3.2 mEq/LCO2 12 mEq/LCl- 111 mEq/LGlucose 68 mg/dLBUN 12 mg/dLCreatinine 1.0 mg/dL

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ECG Sinus tachycardia

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For Examiner

Date:

Examiner:

Examinee(s):

Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)

The learner should be scored (based on level of training) for each item above with one of the following:

NI = Needs Improvement

ME = Meets ExpectationsAE = Above ExpectationsNA= Not Assessed

Critical Actions NI ME AE NA Category1. Perform gastric decontamination with AC

PC, MK

2. Order ASA level and Chemistry panel

PC, MK

3. Volume resuscitate with NS PC, MK4. Alkalinize urine using appropriate formula including K replacement

PC, MK

5. Consult PCC and arrange for dialysis

ICS, PBL, SBP

6. Obtain head CT to evaluate for trauma

PBL, PC, SBP

The score sheet may be used for a variety of learners. For example, in using the case for 4th year medical students, the

key teaching points of the case may be the recognition of shock and treatment with appropriate fluid resuscitation. Other items may be marked N/A= not assessed.

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Category: One or more of the ACGME Core Competencies as defined in the SDOT

PC= Patient CareCompassionate, appropriate, and effective for the treatment of health problems and the promotion of health

MK= Medical KnowledgeResidents are expected to formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to utilize available medical resources effectively, and apply this knowledge to clinical decision making

PBL= Practice Based Learning & ImprovementInvolves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

ICS= Interpersonal Communication SkillsResults in effective information exchange and teaming with patients, their families, and other health professionals

P= ProfessionalismManifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

SBP= Systems Based PracticeManifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

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Keywords for future searching functionsSalicylatesAspirinOverdoseTreatmentToxicology

References:Emedicine: http://emedicine.medscape.com/article/818242-overview. Accessed 11/8/2010.

Dargan PI, Wallace CI, Jones AL. An evidence based flowchart to guide the management of acute salicylate (aspirin) overdose. Emerg Med J. 2002 May;19(3):206-9.

O'Malley GF.Emergency department management of the salicylate-poisoned patient.Emerg Med Clin North Am. 2007 May;25(2):333-46.

Has this work been previously published? No

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http://emedicine.medscape.com/article/818242-overview


Debriefing Materials - Salicylate Toxicity

Sources of Exposure: Salicylates are found in hundreds of over-the-counter (OTC) medications and in

numerous prescription drugs. Pepto-Bismol, a common antidiarrheal agent, contains 131 mg of salicylate per

tablespoon Aspirin or aspirin-equivalent preparations include children's aspirin (80-mg tablets), adult

aspirin (325-mg tablets) Methyl salicylate (eg, oil of wintergreen) (One teaspoon of 98% methyl salicylate

contains 7000 mg of salicylate - more than 4 times the potentially toxic dose for a child who weighs 10 kg)

Pathophysiology: Salicylates stimulate the respiratory center, leading to hyperventilation and respiratory

alkalosis. Salicylates also interfere with the Krebs cycle, limit production of ATP, and increase

lactate production, leading to ketosis and a wide anion-gap metabolic acidosis.

Severity of Ingestion: A 16% morbidity rate and a 1% mortality rate are associated with patients presenting

with an acute overdose. Prognosis is worse for chronic overdose/exposure. The following 4 categories are helpful for assessing the potential severity and morbidity

of an acute, single event, nonenteric-coated, salicylate ingestion: o Less than 150 mg/kg - Spectrum ranges from no toxicity to mild toxicityo From 150-300 mg/kg - Mild-to-moderate toxicityo From 301-500 mg/kg - Serious toxicityo Greater than 500 mg/kg - Potentially lethal toxicity

Organ System Effects: Psychiatric:

o The chronic ingestion of salicylates may produce the appearance of anxiety with its associated tachypnea, difficulty concentrating, and hallucinations. Patients with underlying psychiatric illness may present with symptoms suggestive of an exacerbation of their underlying psychiatric illness (eg, mania, psychosis)

Pulmonary:o Salicylates cause both direct and indirect stimulation of respiration. A salicylate

level of 35 mg/dL or higher causes increases in both rate (tachypnea) and depth (hyperpnea) of respiration. Salicylate poisoning may rarely cause noncardiogenic pulmonary edema (NCPE) and acute lung injury in pediatric patients.

Cardiovascular: o Tachycardia, Hypotension

Neurologic:o Salicylates are neurotoxic; this initially manifests as tinnitus. CNS toxicity is

related to the amount of drug bound to CNS tissue. It is more common with chronic than acute toxicity. Acidosis worsens CNS toxicity by increasing the

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amount of salicylate that crosses the blood brain barrier and increases CNS tissue levels. Other signs and symptoms of CNS toxicity include nausea, vomiting, hyperpnea, and lethargy. Severe toxicity can progress to disorientation, seizures, cerebral edema, hyperthermia, coma, cardiorespiratory depression, and, eventually, death.

Gastrointestinal:o Nausea and vomiting are the most common toxic effects. This can be caused by

CNS toxicity or by direct damage to the gastric mucosa. Dermatologic:

o Diaphoresis is a common sign in patients with salicylate toxicity.

Diagnostic Testing: Chemistry panel

o Repeat as needed Serum salicylate level

o Every 2 hours until the salicylate level falls.o Avoid the use of the Done nomogramo Serum levels determined less than 6 hours postingestion (acute overdose) do not

rule out impending toxicity because salicylates are in the absorption-distribution phase.

o In cases of chronic salicylism, measured toxic levels may be only 30-40 mg/d.o Acute overdoses are often symptomatic at salicylate concentrations higher than

40-50 mg/dL.o Patients with salicylate concentrations approaching or exceeding 100 mg/dL

usually have serious or life-threatening toxicity. Urinalysis: Monitor and maintain an alkaline urine pH every 2 hours during alkalinization

therapy. Maintain a urine pH of 7.5-8 Monitor glucose levels closely. Initial hyperglycemia may give way to hypoglycemia. Obtain hepatic, hematologic, and coagulation profiles for patients with clinical evidence

of moderate-to-severe toxicity. Chest x-ray is indicated if evidence of severe intoxication, pulmonary edema, or

hypoxemia is present. Consider an abdominal x-ray if an aspirin concretion is suspected.

Treatment: Decontamination

o Gastric lavage may be beneficialo Oral activated charcoal, especially if the patient presents within one hour of

ingestion.o Repeated doses of charcoal may enhance salicylate elimination and may shorten

the serum half-life.11 Most experts strongly recommend this for patients with a serious ingestion.

o When enteric-coated aspirin has been ingested or when salicylate levels do not decrease despite treatment with charcoal, WBI should be used in addition to charcoal therapy.

Administer lactated Ringer or isotonic sodium chloride solution for volume expansion at 10-20 cc/kg/h until a 1-1.5-cc/kg/h urine flow is established.

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Alkalinization of blood and urine keeps salicylates away from brain tissue and in the blood, in addition to enhancing urinary excretion.

o When the urine pH increases to 8 from 5, renal clearance of salicylate increases 10-20 times.

o Consider this treatment if the salicylate level is higher than 35 mg/dL.o Single IV bolus of NaHCO 3 at 1-2 mEq/kg. Follow this with a constant infusion of

D5W with NaHCO 3 100-150 mEq/L and KCl 20-40 mEq/L at 1.5-2.5 mL/kg/h to produce a urine flow of 0.5-1 mL/kg/h. Closely monitor the serum electrolytes and urine pH, and maintain the urinary pH between 7.5-8.

o The urinary excretion of salicylic acid is dependent upon adequate serum potassium.

Consultations: Consult with the regional poison control center or a local medical toxicologist for

additional information and patient care recommendations. Consultation with nephrology department personnel is required if hemodialysis is

indicated.o Recommendations for hemodialysis include the following

Severe manifestations of intoxication Refractory or profound acidosis Serum levels higher than 100 mg/dL after acute overdose or serum levels

higher than 40-50 mg/dL in chronic salicylism.

Disposition: Admit patients with major signs and symptoms to an intensive care unit Consult psychiatric service personnel for patients with intentional overdose. Patients with accidental ingestions of less than 150 mg/kg and no signs of toxicity can be

discharged after 6 hours postingestion.

Pitfalls: Failure to diagnose salicylate toxicity in a patient presenting with vague signs and

symptoms, such as anxiety, tachypnea, agitation, delirium, tinnitus, or a combined respiratory alkalosis and metabolic acidosis

Failure to initiate GI decontamination in a patient with acute salicylate ingestion who, subsequently, has recurrent toxicity from a salicylate bezoar

Failure to hyperventilate a patient with severe salicylate poisoning who has just been intubated (when acid-base status had been maintained previously by the patient's own hyperventilation) to prevent lethal acidemia

Failure to diagnose and treat concomitant hypoglycemia in the salicylate-intoxicated patient; more common in children than in adults

Failure to confirm units of measurement may lead to confusion. Always confirm the units of measurement.

Immediately begin therapy in symptomatic patients. Do not wait for the salicylate levels to return from the laboratory.

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