Transcription
Médicos is perfection. Alice once again continuing our discussion about salicylate poisoning. In the previous video, we started talking about it; today, I'll talk about how to diagnose and treat salicylism. With that being said, now let's get started. [Music]
What are the side effects of aspirin? Bleeding, GI upset, peptic ulcer disease/gastritis, hyperventilation—why? Because aspirin stimulates the respiratory center. Tinnitus, since your neural hearing loss. Source: Vettori et al. COSO is followed by metabolic acidosis, and I've discussed it in the previous video. Non-cardiogenic pulmonary edema, renal toxicity, asthma exacerbation. Aspirin can also lead to hypothermia or fever because aspirin is an uncoupler; when you don't produce ATP, you will shift to anaerobic glycolysis, lots of lactic acid—welcome to high anion gap metabolic acidosis, which is never fun. Aspirin can prevent you from clotting, but it can also make you bleed. This is just the fact of life, and when you bleed, you lose blood. Blood contains red blood cells; red blood cells contain hemoglobin; hemoglobin contains heme and globin; heme contains iron and protoporphyrin. When you lose iron in the stool or in the vomitus, you will end up with iron deficiency anemia, which is microcytic anemia. Sometimes it starts as normocytic anemia, but then it shifts into a microcytic anemia. Watch my videos on anemia in my playlist about hematology. The most common subtype of anemia worldwide is iron deficiency anemia. The most common cause of iron deficiency anemia in the developing world is nutritional deficiency. The most common cause of iron deficiency anemia in the modern world is GI bleed.
So, effects of aspirin again include idiopathic thrombocytopenic purpura, Coombs positive hemolytic anemia. I have a video about Coombs tests, direct and indirect, and previous videos in my hematology playlist. Drug-induced esophagitis, allergy, hypersensitivity, and aspirin toxicity, which is the topic of today's video. I talked about the aspirin drug-drug interaction in the previous video, and in the last video, I've told you a joke about two pharmacology professors. So watch the previous video, please. Don't forget: don't give aspirin with warfarin; don't give aspirin with SSRI; don't give aspirin with alcohol; as from penicillin G, aspirin, and vitamin C. More than 100 students have actually listened to me and went to Picmonic; it's a website containing lots of visual, kind of interactive medical mnemonics. It's out of this world, absolutely fascinating. Check the link in the description.
Salicylate poisoning is acute or chronic, and this is the toxic dose depending on your body weight. Signs and symptoms: tinnitus, which is ringing in the ear; nausea; vomiting; don't paint; Rajan's fatigue; stripper lethargy, which counteracts an acidosis or at least tries to suppress your hyperinflation; favor respiratory alkalosis, hold by metabolic acidosis and pulmonary edema. Phases of salicylate poisoning—because doctors are creative, they called them one, two, and three. Very creative and profound stuff. 0 to 12: hyperventilation leading to respiratory alkalosis; 12 to 24: mixed respiratory alkalosis and metabolic acidosis; more than 24 hours: dehydration, hyperkalemia, progressive Hagman—this is really bad. The most common cause of death in salicylate poisoning is cardiopulmonary arrest due to pulmonary edema. When those pharmaceutical corporations print a label on the bottle: keep it out of the reach of children, they're not joking with you; they're not just protecting themselves from lawyers; it's actually good for you and for your kid.
Diagnosis of salicylism: one, comprehensive metabolic panel, or CMP; two, complete blood count, or CBC. Let's start with CBC first, and you have hemoglobin, hematocrit—those are red blood cells, white blood cells, and platelets. Very easy. I love those fishbone kind of illustrations. Then the CMP: so the sodium, potassium, chloride, CO2, bicarbonate, and glucose. Let's memorize them: sodium and potassium, they go together. If you have been in this business for five seconds, you know the sodium potassium are kind of cousins. Chloride and bicarbonate, or I'm sorry, chloride and CO2—so sorry, bicarbonate. This is kidney function, and then glucose—this is your pancreas and your diabetes stuff. Sodium, potassium—to say is to think too with the kidney and pancreas, because you have two kidneys and one pancreas. Hahaha. Okay, blood salicylate level: yeah, if you suspect salicylate poisoning, let's measure the level of salicylate in the blood. Blood glucose level might be low—hypoglycemia—and check the urine; you might find some salicylate there. And, of course, you will need arterial blood gas to measure the pH, acidosis, alkalosis—all of this crazy stuff.
The video is not over yet; we still have to talk about treatment, but please don't forget: I have the perfect snails ultimate notebook about lymphoma, plus 21 lymphoma cases, plus 25 bleeding cases on patreon.com/medicosis. Treatment of salicylism: no antidote for aspirin; there is none, zero, nada. Even juice cleansers can't do it. Okay, stupid stuff, and you guys believe those online gurus. Look, businessmen and businesswomen are smart. You, so like, juice cleanser, treat your little naturally? What? Like what the flip does natural mean? Like sunlight is natural, and it causes melanoma, so shut up. Just because it's natural doesn't mean it's good. Like think for five seconds, and you will realize that your cute puppy is natural; the lion killing the zebra and eating it alive is also natural. Welcome to life. In many cases, cancer is natural; chemotherapy is not. So, first, there is no antidote for aspirin. Don't forget your ABCs; any good doctor should never forget ABCs: first, airway, breathing, and circulation. I don't care about anything; ABCs first. Gastric decontamination with activated charcoal. Now, if you are a dinosaur like me, born in Egypt, I've studied lots of crazy stuff, such as the syrup of ipecac, which no one uses today, like ever, but we still had to study it, and the professors used to ask us about the syrup of ipecac, which they know nobody uses it. Okay, that's why I hate pharmacology. Alright, then they have the salt. If you are stranded in a desert and you have a patient with aspirin toxicity, you don't have the activated charcoal, you don't have the syrup of ipecac, what should you do? Yeah, let him or her swallow as lots of salt as possible; then they will vomit the salt with the aspirin. This is, of course, brutal, but it's better than dying from cardiopulmonary arrest. This is like archaic stuff that you will never use in real life. The only gastric decontamination that we still use is the activated charcoal.
IV fluid: why? To maintain the effective arterial blood volume, and I've talked about this in my series about fluids, electrolytes, and acid-base disturbance. When you maintain the volume inside your blood vessel, you are maintaining their urine output. What do you think urine comes from? From your blood. Hello, your precious crocodile tears, they come from your blood. Any secretions come from the blood: your saliva, blood; your sweat, blood; etc., etcetera. I said, when you maintain a blood volume, you're maintaining a urine output, provided that the kidney is normal, and this is profound. Aspirin overdose can lead to dehydration; give IV fluid. What kind of fluids? Dextrose 5% in water is great. Why? You maintain a volume, and it's also good because it contains dextrose, and those patients, I've told you like five minutes ago, can suffer from hypoglycemia; it's good to give them dextrose. If they are not hypoglycemic, you can give them normal saline. Alkalinization of the urine, and you have two methods. Right now, we use sodium bicarbonate; historically, we used to use acetazolamide. When everything fails: hemodialysis to remove aspirin from the system. When the bleep hits the fan. That's why I love—I love the American people because they are—the imagination is just great. Like when you are describing yourself to somebody that life is treating you so badly, like it's just the best.
Let's talk about alkalinization of the urine. In chemistry, we have learned an important rule: like dissolves like; and in pharmacology, I've made up a new rule: like reabsorbs like, when we're talking about the kidney. Translation: acetyl salicylic acid is an acid. Okay, if you want it to be reabsorbed, put it in a like environment, also known as an acidic environment. So, in an acidic medium, this aspirin will be reabsorbed into the blood. Of course, if you put the aspirin in an alkaline medium, for on the other hand, it will be secreted into the urine. So, in cases of salicylate toxicity, we have lots of acetyl salicylic acid in the system, and we would like to get rid of it—pee it out, baby—and get it out of the system. Put it in an alkaline medium, called alkalinization of the urine. What alkaline medium you can use? This great sodium bicarbonate, or historically speaking, acetazolamide. For some reason, pharmacology professors tell you if you wanna be more sophisticated. Alkalinization of the urine will lead to increased ionization of weak acids, and aspirin is a weak acid. When you increase ionization of anything, you make it more water-soluble. I don't understand. Okay, it's like sodium chloride. Why is it water-soluble? Because it's ionizable in water into sodium and chloride. Hey, it's sodium chloride; water-soluble; goodness gracious. Stupidity has no limits. Look, brother, no matter how broke you are, I'm sure there is some table salt in your house. Get a teaspoon and add some salt into a glass of water; start steering it, and then drink. Salty, isn't it? Yes. What happened? Sodium chloride was ionized, therefore water-soluble, therefore salty water. Welcome to life. And when it's water-soluble, the kidney will love you because it can eliminate it.
The incidence of aspirin toxicity has been declining over the years. Do you know why? Maybe because doctors have been working with their local communities to raise awareness? Nope. Could be the government is spending more on health care? Wrong; that won't do it. Maybe the rich private donors, like Bill Gates, Warren Buffett, and the Rockefeller Foundation have created an anti-drug overdose initiative? No, they didn't. Is it possible that Congress has passed a new bill called the Salicylic Acid Toxicity Separation Act, or SASTA? No, never heard of it. The real reason the incidence of aspirin toxicity is going down is because other pain medications are now available, like ibuprofen and Tylenol. When you have less people taking aspirin, you'll have less people getting toxicity from aspirin. Era called common sense. But what about all of the old people that are taking aspirin to prevent from strokes? Remember, this is baby aspirin, 81 milligrams; in the United States, it's a very low dose; the chances of you getting toxicity from this is minimal. So, in brief, the incidence of aspirin is going down because people are having different alternatives. So, for those weird people who are asking: why do we need 17 different types of pain medications on the shelf anyway? Man, those greedy pharmaceutical corporations are killing us. They are not killing people any more than the fact that Bayer AG is making aspirin to make you bleed. No. And if you have two neurons that synapse, you would know that if you—if they killed you, you won't be able to buy medicine from them anymore, and they will lose money because they have lost a customer. Called common sense. So I think you should think a second time. It's generally good to give people more choices; nothing is worse than having no choice. But aspirin 325, and your child ends up swallowing 23 tablets while you are busy talking to your mom over the phone about the new show on Netflix that you're bingeing on. It's called common sense, folks. I give you the same advice that grandma gives you, except that I keep my teeth in. Thank you for watching.
Quiz time. Now you know that sodium bicarbonate and acetazolamide can alkalinize the urine. The question is: how can we acidify the urine? Try to mention three things, or three whatever. Let me know down below in the comments. If you need to know more about aspirin, check the PDF on patreon.com/medicosis. I just have lots of great stuff, including the number needed to treat. Thank you so much for watching. Please subscribe and hit that bell. You can get all of my video notes on patreon.com/medicosis, and I'll send you my bloody Dropbox links. Thank you so much, guys, for watching. As always, be safe, stay happy, and study hard. This is Médicos is perfection. Elsewhere medicine makes perfect sense.