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Educate and NEURS parents

Assessment

CBC, CMP, Arterial blood gas

Low glucose, elevated BUN, hypokalemia, hypocapnia, alkalemia, low bicarb

Physical Exam II

HEENT: Dry mucous membranes. Fontanelle slightly sunken. PERRL. TM’s clear.

 

Abdominal: Soft, nondistended. Positive but hypoactive bowel sounds.

 

Neurological: Difficult to arouse, intermittently crying with stimulation. Symmetric facial movement when crying. Moves all extremities. Normal tone, reflexes.

 

Skin: No rash noted. Capillary refill >3 sec.

Save patient's life

Plan

Monitor patient and implement plan.

Make diagnosis

Order tests to narrow differential

Differential

IV serum and urninary alkalinization (D10 W with 100 mEq / L of sodium bicarbonate) at 2x maintenance.

Physical Exam I

Vitals:

T 40.5 C (reference 36.5-37.5)

R 70 (reference 30-45)

P 195 (reference 90-140)

BP 78/46 (reference 70-90/50-65)

 

Length: 65 cm (75%ile)

 

Weight: 7.7 kg (90%ile)

 

General: Well-nourished infant girl, listless, difficult to arouse, in significant respiratory distress

 

Chest: Extremely tachypneic and hyperpneic, significant retractions. Good air movement, clear breath sounds.

 

Cardiovascular: Tachycardic. 1+ peripheral pulses, cool extremities. No murmur.

Chest X-ray

Normal, hyperpnea gastric bubble

Salicylate Toxicity

Objective

History of presenting illness

Revise plan as necessary

Revisit history

Nathan McDonald

May 8, 2015

Five-month-old girl, well until 4 days prior developed low grade fever, rhinorrhea, nasal congestion. Decreased oral intake, difficulty sleeping.

Today, worsened dyspnea and not eating at all. No wet diaper in 12 hr.

Order further lab tests

CC: My baby is having trouble breathing.

Subjective

Intubate patient

Birth history

Order Tox Screen

Tidal volume: 6cc/kg

RR = 20

FiO2 = 0.4

Mother is G5P4 (1 SAB). Good prenatal care. Maternal prenatal labs significant only for Group B Strep vaginal positivity, treated at birth with antibiotics. NSVD, home on DOL #2. Immunizations up to date, including 2 and 4 month immunizations.

Urine alkalinization increases salicylate excretion

Child's sats drop and becomes apneic

Salicylate poisoning

Salicylate level: 92mg/dL

PMH and SH

PMH: 1 significant viral illness at 2 months of age, no hospitalization.

Medications and allergies

ROS

SH: Lives at home with parents, 3 siblings (ages 2 y, 7 y, and 12 y), and grandmother.

No diarrhea. No rash.

Allergies: None

Medications: D-visol pediatric multivitamin. For the congestion and rhinorrhea, family has been applying a salve to the baby’s chest a number of times a day, as well as giving the baby an OTC pediatric cold preparation. The salve is a type of “deep heating rub”.

Decreased prothrombin formation, increasing the INR

Arterial blood gas: pH 7.18, PCO2 55 mmHg, PaO2 165, HCO3- 12

Compensatory increased renal excretion of potassium in an effort conserve H+

Isotonic saline administered.

Salicylate stimulates respiratory center leading to hyperpnea and respiratory alkalosis.

Salicylate poisoning uncouples oxidative phosphorylation and inhibits Krebs cycle enzymes leading to a decrease in glucose levels.

Compensatory depletion of bicarbonate and therefore the buffering system for the metabolic acidosis

Inhibition of Krebs cycle enzymes and subsequent lipid metabolism generates a metabolic acidosis

Elevated temperature from uncoupled ox-phos

Saline-induced hyperchloremic metabolic acidosis

Elevated anion gap due to increase in unmeasured anions.

Dehydration

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