139 Aspirin and NSAID

Question 1

How does aspirin and salicylates work?

Answer 1

Inhibit the Cox enzyme, particularly one, which then inhibits prostaglandins and thromboxane

Question 2

Where does aspirin undergo bio transformation vs excretion

Answer 2

Liver.
Kidneys

Question 3

What is the regular half-life of aspirin as compared to in an overdose?

Answer 3

2 to 3 hours
Can be up to 12
In an overdose, the peak concentration level is around 4 to 6 hours
And in enteric coated formulas this can be up to 24 hours

Question 4

List five sources of salicylate other than aspirin

Answer 4

Tiger bomb.
Oil of wintergreen methyl
Pepto-Bismol, which is bismuth
Anti-aging creams
Excedrin migraine

Question 5

Normally aspirin undergoes first order kinetics. What does this mean?

Answer 5

This means that with increasing concentrations, the metabolism increases

Question 6

What is the issue with at overdose levels aspirin changing from first order kinetics to zero?

Answer 6

This means that rate of metabolism is independent rate of ingestion

Question 7

Therapeutic dose of aspirin in mg/kg?
g total?

Answer 7

100-300
oftencited 150mg/kg

6g

Question 8

What dose is concerning for toxic in aspirin?

Answer 8

> 200-300mg/kg

Question 9

Lethal aspirin dose mg/kg

Answer 9

> 500

Question 10

At physiologic pH what state is salicylic acid in? (ionized vs not)

Answer 10

ionized!

Question 11

As pH decreases, what happens to physiologic state of aspirin?

Answer 11

changes to nonionized so it can then permeate the lipidd bilayers of the cell membranes therefore incr cns concentration

Question 12

What are the metabolic effects of salicylate toxicity?

Answer 12

limits atp production through interference of citric acid cycle
uncouples ox phos and accumulates pyruvate and lactic acid
increase FA metabolism, increasing ketones
renal loss of bicarb and accumulates inorganic acids
hypokalemia furthers resp alk, vomiting, uncoupling

Question 13

What are the lung effects of salicylate toxicity?

Answer 13

stimulate resp drive in medulla
incr sn to pco2 and pH increasing ventilation
carotid and chemo receptor stim
late stage ards

Question 14

What are the brain effects of salicylate toxicity?

Answer 14

neuroglycopenia
as compared to rest of body ++ low
confusion, agitation, seizure coma, neuronal dysfunction and cerebral edema

Question 15

What are the GI effects of salicylate toxicity?

Answer 15

ulcers
nausea, vomting

Question 16

What are the GUeffects of salicylate toxicity?

Answer 16

renal loss bicarb = NAGMA

Question 17

What are the ear effects of salicylate toxicity?

Answer 17

inhib cochlear cox = tinnitus, hearing loss

Question 18

What are the heme effects of salicylate toxicity?

Answer 18

plt dysufnc = bleed

Question 19

What are the expected acid base abnormalitiies in early salicyclate toxicity

Answer 19

alkalemia
resp alkalemia
metaoblic alk
urine alkyurea

Question 20

What are the expected acid base abnormalitiies in IM salicyclate toxicity

Answer 20

resp alk
metabolic acidosis
urine acid

Question 21

Name expected abnormalities in late stage salicylate toxicity

Answer 21

Metabolic and resp and urine acidosis

Question 22

Rosen’s recommended management of ASA overdose if they come in within 1-2 hours?
What about for bezoar or enteric coat?

Answer 22

Charcoal
Multidose charcoal

Question 23

What volume status is the goal for a salicylate overdose?

Answer 23

Euvolemic
Non cardio pulmonary edema is concern

Question 24

How to alkalinize the urine in as toxicity

Answer 24

Bolus 1-2 A of bicarb then run a D5W infusion with 3 A of bicarb per litre with 40 of KCl at a rate of 1.5 to 2 times maintenance rate

Question 25

How often do you check the urine pH and labs?

Answer 25

Every two hours

Question 26

What goal of PH you aiming to for the urine?

Answer 26

7.5 to 8 or greater

Question 27

What is your goal arterial pH in a aspirin overdose?

Answer 27

7.5 to 7.6

Question 28

What is your goal potassium in a aspirin overdose

Answer 28

Over 4.5

Question 29

What is your goal? Urine output in an aspirin overdose

Answer 29

You’re an output of 2 to 3 cc per kilogram per hour

Question 30

If your ASA overdose patients starts seizing, has confusion, agitation or coma: step one?

Answer 30

neuroglucopenia give glucose

Question 31

Name 5 indications for hemodialysis in an ASA overodse

Answer 31

1. pH <7.1-7.2 2. salicyclic acid level > 100mg/dl or >40mg/dl chronic 3. CNS - ams 4/ resp = new hypoxemia requiring o2 5. liver failure 6. renal fialure 7. rapidly rising level 8. standard therapy fails

Question 32

do you want to intubate an ASA overdose patient?

Answer 32

no

Question 33

Describe your intubation of an ASA overdose patient

Answer 33

1. really don't want to 2. maintain/exceed high resp rate prior to intubation to avoid dropping pH so more salicylate shifts into CNS 3. bolus 2meq/kg of sodium bicarb prior 4. ketamine awake intubation to minimize apnea or possible - if no time to plan for awake then RSI with ketamine and roc 5. match preintubation ventilation vbg q2h post dialysis plan

Question 34

What is the pediatric risk of an ASA overdose?

Answer 34

they really can't increase their ventilatory reserve so they miss the whole resp alkalosis stage

Question 35

Risks specific to a pregnant ASA overdose

Answer 35

they cross placenta high concentration in fetus than mom without any ability of fetus to metabolize this (they breath via umbilical cord so no resp) and they may be effected first before mum presents plan for delivery