254 Emergency Medicine
nausea, vomiting, tinnitus, fever, diaphoresis, and confusion. Salicylates
are capable of producing several types of acid-base disturbances. Acute res-
piratory alkalosis, without hypoxia, is caused by salicylate stimulation of
the respiratory center in the brainstem. If the patient is hypoxic, salicylate-
induced noncardiogenic pulmonary edema should be considered. Within
12 to 24 hours after ingestion, the acid-base status in an untreated patient
shifts toward an anion gap metabolic acidosis because of interference with
the Krebs cycle, uncoupling oxidative-phosphorylation, and increased
fatty acid metabolism. A mixed respiratory alkalosis and metabolic aci-
dosisis typically seen in adults.
(a)Diphenhydramine is a common decongestant that has antihista-
minergic and anticholinergic properties. Overdoses may present as an anti-
cholinergic toxidrome, including altered mental status, mydriasis, flushed
skin, hyperthermia, and dry mucous membranes. The antihistaminergic
properties may cause sedation. (b)Ibuprofen overdose includes GI symp-
toms (nausea, vomiting, and epigastric pain) and mild CNS depression.
(c)APAP overdose usually lacks clinical signs or symptoms in the first 24 hours.
Patients may have nonspecific GI complaints. (e)Pseudoephedrine is a com-
monly used decongestant. An overdose may present with CNS stimulation,
hypertension, tachycardia, and dysrhythmias.
226.The answer is c.(Rosen, pp 2064-2066.)Thesympathomimetic syn-
dromeusually is seen after acute abuse of cocaine, amphetamines, or decon-
gestants. Patients are usually hypertensiveandtachycardicand exhibit
mydriatic pupils.In massive overdoses, cardiovascular collapse can result in
shock and wide-complex dysrhythmias. CNS effects include seizures. Sym-
pathomimetic syndrome is sometimes difficult to distinguish from anticholiner-
gic syndrome. The difference is that patients usually present with dry mucous
membranes with an anticholinergic overdose, whereas patients are diaphoretic
with sympathomimetics.
(a)The anticholinergic syndrome typically presents with delirium, mum-
bling speech, tachycardia, elevated temperature, flushed face, dry mucous
membranes and skin, dilated pupils, and hypoactive bowel sounds. (b)The
cholinergic syndrome is commonly remembered by the mnemonics SLUDGE
or DUMBBELS. (d)Opioids are part of the sedative-hypnotic syndrome. It
typically presents with sedation, miosis, respiratory depression, hypotension,
bradycardia, hypothermia, and decreased bowel sounds. (e)Serotonin syn-
drome is characterized by altered mental status, fever, agitation, tremor,
myoclonus, hyperreflexia, ataxia, diaphoresis, shivering, and sometimes