Faculty Bibliography

Objective: Both acute and chronic salicylism constitute a significant cause of mortality and morbidity in poisoned patients. While some authors have suggested that there is no need to screen for salicylate toxicity in the absence of a history or an anion gap acidosis, here we present a case of non-anion gap acidosis in a patient with significant salicylate poisoning. Case report: A 59-year-old man with no known significant past medical history was brought to the Emergency Department with depressed mental status. On arrival, he was tachypneic (26/ minutes) with shallow respirations, temperature of 37.3 degreeC, blood pressure 129/79 mmHg, heart rate 81 bpm, and oxygen saturation 94% on room air. Venous blood gas analysis showed: pH 7.4 and pCO2 28mmHg. Initial blood tests revealed: sodium 135 mmol/L, potassium 4.6mmol/L, chloride 105 mmol/L, bicarbonate 19mmol/L, blood urea nitrogen 19 mmol/L, creatinine 132 mumol/ L, glucose 6.7mmol/L, and anion gap 11 mmol/L (normal range 8-16 mmol/L). He was intubated and a subsequent arterial blood gas showed: pH 7.14 and pCO2 77 mmHg. Blood salicylate concentration obtained on initial screening was 0.61 mmol/L (therapeutic < 0.22 mmol/L). Intravenous bicarbonate infusion was started, he was given multi-dose activated charcoal and hemodialysis performed. He was extubated five days after admission and medically cleared on day 7 of admission. Conclusion: Significant salicylate ingestion is a well-recognized cause of elevated anion gap metabolic acidosis. Sporer et al. suggested that there is no need to screen for salicylate ingestion in the absence of anion gap acidosis [1]. However, here we demonstrate the presence of a non-anion gap metabolic acidosis associated with a clinically severe salicylate ingestion. There are multiple explanations for this phenomenon. Multiple chemistry analyzers including the one used at our hospital uses a proprietary ion-sensitive chloride electrode. With this analyzer, salicylate concentrations of 0.145 mmol/L and more than 0.43 mmol/L are known to cause a 4% and 15% false increase in chloride concentrations, respectively. This can erroneously cause a normal or even negative anion gap. In addition, acute salicylism occasionally causes proximal renal tubular dysfunction that can contribute to a non-anion gap acidosis. Clinicians should be compulsive about screening for salicylates in undifferentiated poisoned patients as routine chemistry tests may be insufficient to show salicylate toxicity

OBJECTIVES: To develop key messages for methadone and buprenorphine safety education material based on an analysis of calls to the NYC Poison Control Center (NYC PCC) and designed for distribution to caregivers of young children. METHODS: Retrospective review of all calls for children 5 years of age and younger involving methadone or buprenorphine from January 1, 2000, to June 15, 2014. A data abstraction form was completed for each case to capture patient demographics, exposure and caller sites, caller relation to patient, qualitative information regarding the exposure scenario, the product information, if naloxone was given, and the medical outcome of the case. RESULTS: A total of 123 cases were identified. The ages of the children ranged from 4 days to 5 years; 55% were boys. All exposures occurred in a home environment. The majority of the calls were made to the NYC PCC by the doctor (74%) or nurse (2%) at a health care facility. Approximately one-fourth of the calls came from the home and were made by the parent (22%) or grandparent (2%). More than one-half of the exposures involved methadone (64%). Naloxone was administered in 28% of cases. Approximately one-fourth of the children did not experience any effect after the reported exposure, one-half (51%) experienced some effect (minor, moderate, or major), and there was 1 death (1%). More than one-half of the children were admitted to the hospital, with 40% admitted to critical care and 13% to noncritical care. Approximately 23% were treated and released from the hospital, and 20% were lost to follow-up or never arrived to the hospital. The remaining 4% were managed on site without a visit to the hospital. CONCLUSION: Exposures to methadone and buprenorphine are dangerous with some leading to serious health effects. Safe storage and disposal instructions are needed for homes where children may be present.