A young male presents after an overdose of a commonly used drug.
1.
Acute uncompensated respiratory alkalosis with mild hypokalaemia
Mild increase in A-a gradient
2. Suggests significant Salicylate toxicity
VQ mismatch/ shunt – ?? aspiration from vomiting, other
3. Management Issues;
Avoid intubation
Attention to ABC
A, B – O2 supplementation as reqd (Sats>95%)
C – fluid therapy, avoid hypotension, aim for UOP 1-2 ml/kg/hr. If AMS, Pulm oedema – Inotropic support
Gastric decontamination – normal GCS, within 2 hrs of ingestion – indication for multidose AC (50g followed by 25 g every 1-2 hrs). WBI only with massive ingestions
Check for co ingestants. Paracetamol level, ECG
Specific therapy
– glucose for AMS (Neuroglycopaenia, even if BSL normal), 100ml bolus of 50% dextrose (repeat as required)
– Correct hypokalaemia
– Alkalanise blood and urine with NaHCO3 100mEq stat and then infusion – aim for pH 7.50 to 7.59
– Avoid Acetozolamide – prevents HCO3 reabsorption in kidney
– 2 hrly Salicylate levels until trending down with clinical improvement
4. Indications for Haemodialysis:
– Renal Failure
– Clinical deterioration despite optimal supportive care
– Salicylate level >7
– Cerebral/ Pulm oedema
– Fluid overload where HCO3 infusion cannot be given
– Profound altered mental state
Read up on the Ventilation strategy for these patients