Case Files of the University of California, San Francisco Medical Toxicology Fellowship: Seizures and a Persistent Anion Gap Metabolic Acidosis

Abstract

A 17-year-old female was brought into the emergency department (ED) by ambulance after being found unresponsive by her parents at home. She was last seen normal 4 hours previously, and a text message sent to her boyfriend indicated her intention to overdose on ondansetron and loratadine. Upon arrival of emergency medical services, she was administered naloxone without effect, and supportive measures including bag valve mask ventilation were initiated. En route to the ED, she had a witnessed generalized tonic-clonic seizure, and she was treated with midazolam.In the ED, the patient's vital signs were BP 125/53 mmHg, HR 130/min, RR 18/min, and temperature 33.9°C (rectal). Her physical exam was notable only for a Glasgow Coma Scale (GCS) of 3 without a gag reflex. Her pupil size was not commented upon, and she was immediately intubated for airway protection.

Ibuprofen-Associated Hypokalemia and Metabolic Acidosis: Systematic Literature Review

“…For the final analysis, we retained 41 scientific reports published since 1985: 22 from America (United States of America, N = 20; Canada, N = 1; Mexico, N = 1), 12 from Europe (United Kingdom, N = 9; Germany, N = 2; Spain, N = 1), 6 from Australia, and 1 from Asia (Saudi Arabia, N = 1). 2,8-47 Thirty-nine articles were published in English, 1 in Spanish, and 1 in German. The mentioned reports described 50 cases (14 children and 36 adults).…”

“…Twenty-six cases of hypokalemia, metabolic acidosis, or both hypokalemia and acidosis were considered acute. 2,8-17,19-21,23,25-27,29-31,37,40,43 Twenty-four cases were observed after a single dose of ibuprofen: 96 mg/kg in 1 case, 101 to 500 mg/kg in 5 cases, 501 to 1000 mg/kg in 9 cases, >1000 mg/kg in 8 cases (this information was not provided in 1 case). The remaining 2 cases ingested ibuprofen 28 mg/kg body weight daily, respectively, 67 mg/kg body weight daily for 3 days or less.…”

“…In addition to ibuprofen (Table 1), various drugs had been administered in 28 cases. 11-13,22-24,26,29-40,42,43,45…”

“…In addition to ibuprofen (Table 1), various drugs had been administered in 28 cases. [11][12][13][22][23][24]26,[29][30][31][32][33][34][35][36][37][38][39][40]42,43,45 The renal tubular handling of potassium or acid-base balance was investigated in 19 cases. The urinary findings were consistent with an altered renal tubular function were noted in 14 of them (Table 2).…”

Metabolic acidosis in multi drug poisoning with antidepressants and antipsychotics

“…Hypoxia, hypotension, and seizure also are the predisposing factors for metabolic acidosis, which increases the severity of poisoning. [ 12 13 14 ]…”