Module 7: Case Studies and Practical Applications

7.1 Practice Case Studies

Scenario 1: 

You are consulted on a 50-year-old woman who took an unknown amount of aspirin 12 hours ago. She is now lethargic with rapid shallow breathing. Her salicylate level is 78 mg/dL, pH is 7.1 and creatinine is 2.3 mg/dL. What is your interpretation and recommended management?

Scenario 2:

A 3-year-old boy is brought to the ED by his parents who found an open bottle of Pepto-Bismol. He is vomiting, tachypneic but has a normal salicylate level. However, his anion gap is elevated. What additional work up and management would you recommend?

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7.2 Cast Studies Discussions

Scenario 1 Discussion:

This patient with a salicylate level of 78 mg/dL and acidosis with a pH of 7.1 has severe acute salicylate toxicity. The elevated creatinine also suggests compromised renal clearance.

Despite being 12 hours after ingestion, her clinical status indicates she is deteriorating and requires aggressive intervention. I would recommend starting intravenous sodium bicarbonate to alkalinize her urine and prevent further redistribution into the CNS.

However, given her high level, renal dysfunction and lethargy, urgent hemodialysis is strongly indicated regardless of urinary alkalinization success. This offers the greatest chance of preventing further clinical decline and fatal outcomes.

Scenario 2 Discussion:

Although this child has a normal salicylate level, the elevated anion gap metabolic acidosis suggests significant salicylate toxicity is present but not yet reflected in the level due to delayed absorption from the Pepto-Bismol.

The vital first step is to administer intravenous dextrose despite his normal fingerstick glucose to address potential neuroglycopenia contributing to his vomiting. Starting intravenous sodium bicarbonate to alkalinize his urine is also indicated.

Frequent rechecks of his salicylate level, anion gap and mental status are needed to ensure he is responding to treatment and not deteriorating as absorption continues. Consultation with a pediatric toxicologist and discussions with poison control are advisable given his young age.