1 Let’s talk #toxicology! Dr. Kelly Sopko @kelly_sopko shared a RIVETING case of a patient with frequent readmissions, now presenting with agitated delirium and admitted for cough + suspect ETOH intoxication. A curiously broad Ddx! (thread) #clinicalreasoning #medtwitter #MedEd 
2 70 year old M PMH bipolar disorder, chronic low back pain, 17 readmits over past 1 year, presents with cough, requesting detox and develops worsening agitation after a dose of ativan given in ED. Thoughts, @VUMCInternalMed and #medtwitter? @VUMCHospitalMed team-generated ddx:
3 Initial labs found here. Anything stand out? Are you impressed? This is from the pre-#COVID19 era, mind you:
5 Never let a good opportunity to use Winter’s Formula go to waste. Don’t forget to calculate the OG/osmolar gap: #toxicology
6 Given the presence of unexplained Anion Gap Metabolic Acidosis #AGMA + Acute Respiratory Alkalosis, what additional laboratory studies would you need to order? (Subtle hint via the Weeping Willow tree here): #toxicology #clinicalreasoning #medtwitter #MedEd
7 Acetaminophen level returned < 1, but Salicylate level 62.2 mg/dL (!!!), prompting a midnight phone call to nephrology for emergent hemodialysis, despite no hyperkalemia and normal renal function 🧐 The diagnosis? #medtwitter #MedEd
8 Surreptitious Salicylate toxicity! Beware OTC meds, note aspirin dosages with these common and more obscure offenders. Wintergreen oil (1ml = 1400mg!) >> BC Powder (845mg per dose!) #toxicology #medtwitter #MedEd
9 Symptomatology differs in acute versus chronic ingestion. Chronic = less likely to correlate with serum levels. See recent @NEJM review: nejm.org/doi/full/10.10…
10 Enlightening pathophys: respiratory alkalosis + oxidative uncoupling/elevated AG + alkalemia. Get the picture? #toxicology #MedEd #medtwitter
11 Salicylate toxicity Tx, Do’s and Don’ts: spectrum from activated charcoal and bicarb gtt all the way to HD (if AMS/AKI/hypoxia or level >90) and mechanical ventilation for airway protection. Don’t let lack of traditional HD indications confound you, AMS +⬆️AG = enough! @NEJM
12 But first things first, keep your mind open! Avoid cognitive bias such as Anchoring Effect and Bandwagon Bias. Helpful reminders for diagnostic excellence included here: #medtwitter #MedEd #clinicalreasoning #hospitalmedicine
13 Thx 4 following along this great #toxicology case! A curiously strong case of salicylate toxicity p/w unexplained AMS+AGMA+resp alkalosis. Subtle reasoning➡️ by astute clinician @kelly_sopko➡️lifesaving HD overnight. Beware OTC meds, essential oils, and cognitive bias! FIN
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