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Acetaminophen
16%
42/264
Aspirin
47%
125/264
Ethylene glycol
10%
26/264
Insulin
6%
15/264
Tricyclic antidepressant
17%
44/264
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This patient who presents with altered mental status and acute respiratory alkalosis with normal bicarbonate levels after an overdose is most likely experiencing the effects of aspirin toxicity. Salicylate toxicity most commonly occurs due to an intentional or accidental overdose of aspirin in suicidal patients or patients taking chronic pain medications. This toxidrome consists of early hyperventilation due to the direct stimulation of respiratory centers in the brainstem. Patients will present within 1-2 hours with early findings of acute respiratory alkalosis (decreased PCO2 levels). After 6-12 hours, aspirin will also lead to uncoupling of oxidative phosphorylation and a resulting lactic acidosis, so late presenting patients will present with a mixed metabolic acidosis/respiratory alkalosis picture. Other presenting symptoms include nausea, vomiting, tinnitus, lethargy, and coma in cases of severe poisoning. Incorrect Answers: Answer 1: Acetaminophen poisoning may also present with altered mental status; however, this toxidrome will present with acute fulminant hepatic failure, jaundice, and abdominal pain rather than respiratory alkalosis. Answer 3: Ethylene glycol intoxication may also present with altered mental status; however, this toxidrome will present as a metabolic acidosis rather than a respiratory alkalosis. The pH above 7.4 in this patient indicates that this patient is in alkalemia, which can be caused by respiratory alkalosis (PCO2 < 40 mmHg) or metabolic alkalosis (HCO3- > 28 mEq/L). This patient's low PCO2 indicates that she is in respiratory alkalosis. Answer 4: Insulin overdose may also present with altered mental status due to hypoglycemia; however, this toxidrome will present with very low blood glucose rather than acute acid/base derangements. Answer 5: Tricyclic antidepressant toxicity presents with convulsions, coma, and cardiotoxicity. Unlike aspirin overdose, tricyclic antidepressants can lead to respiratory depression and subsequent respiratory acidosis rather than alkalosis. Bullet Summary: Aspirin overdose presents with early respiratory alkalosis followed by late metabolic acidosis resulting in a mixed metabolic acidosis/respiratory alkalosis picture.
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