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Anorexia medical instability — USMLE Step 3 MCQ

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HardPsychiatry (Outpatient Management)Anorexia medical instabilityUSMLE Step 3

A 31-year-old woman with severe salicylate poisoning has tinnitus, agitation, pulmonary edema, pH 7.48, PCO2 21 mm Hg, bicarbonate 16 mEq/L, and salicylate concentration 92 mg/dL. Sodium bicarbonate infusion is running, but worsening hypoxemia requires intubation while hemodialysis is mobilized. Which ventilation strategy is most important immediately after intubation?

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Correct answer: E — Maintain preintubation minute ventilation and alkalemia while preparing urgent hemodialysis

The best answer is “Maintain preintubation minute ventilation and alkalemia while preparing urgent hemodialysis”. Salicylate distribution into the brain accelerates if pH falls. A poisoned patient may sustain an enormous compensatory minute ventilation; sedation and ordinary ventilator settings can abruptly raise PCO2 and cause acidemia, clinical collapse, and death. When intubation is unavoidable, preoxygenation, bicarbonate, and very high minute ventilation must preserve alkalemia while urgent hemodialysis proceeds.

Reference: ACMT Guidance Document: Management Priorities in Salicylate Toxicity: https://pmc.ncbi.nlm.nih.gov/articles/PMC4371029/