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Low glucose, elevated BUN, hypokalemia, hypocapnia, alkalemia, low bicarb
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.
IV serum and urninary alkalinization (D10 W with 100 mEq / L of sodium bicarbonate) at 2x maintenance.
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.
Normal, hyperpnea gastric bubble
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.
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
Salicylate poisoning
Salicylate level: 92mg/dL
PMH: 1 significant viral illness at 2 months of age, no hospitalization.
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.