Hemorrhagic Encephalopathy From Acute Baking Soda Ingestion

Adrienne Hughes, MD; Alisha Brown, MD; Matthew Valento, MD

Disclosures

Western J Emerg Med. 2016;17(5):619-622. 

In This Article

Case Report

A 33-year-old male with a history of schizophrenia and polysubstance abuse presented to the emergency department (ED) with altered mental status. Emergency medical technicians reported that the patient was discovered in the middle of the street, agitated and confused with an empty box of baking soda in his pants pocket.

On initial evaluation, the patient appeared alert, tremulous and distressed. His vitals were temperature 35.7°C (96.2°F), heart rate 124 beats/min, respirations 18 breaths/min, blood pressure 126/93, oxygen saturation 94% on room air. The physical examination was significant for a thin male, rocking back and forth, mumbling incoherently and forcefully blinking his eyes. The head and neck examination was notable for horizontal nystagmus, intermittent involuntary facial twitching, moist mucus membranes and no facial droop. Pupils were equal, round, and reactive to light bilaterally. The cardiac examination revealed regular tachycardia. Neurologic examination was significant for a coarse tremor to his arms and upper torso. He would intermittently lift his legs and arms off the bed then slam them down on the stretcher. He was stuttering, disoriented, and unable to answer questions. Cerebellar function could not be tested due to the patient's mental status. The rest of his exam was normal.

Initial laboratory values were Na 172mEq/L, K 2.5mEq/L, chloride 98mEq/L, CO2>45mEq/L, glucose 433mg/dL, BUN 16mg/dL, creatinine 1.85mg/dL, magnesium 3.2mg/dL, phosphate<1mg/dL, and calcium of 11mg/dL. Liver function tests were remarkable for a bilirubin of 1.4mg/dL, total protein of 8.5g/dL, albumin of 5.6g/dL. White blood cell count was 11.6 cells/microL and his hemoglobin was 17g/dL. A room air venous blood gas measurement 7.53, pCO2 60mmHg, pO2 39mmHg, HCO3 50mEq/L, with a base excess of 21.6mEq/L. The electrocardiogram (EKG) showed sinus tachycardia with a prolonged QTc of 528msec. Urinalysis: pH of 8.52 and granular casts. Serum osmolality was 364 mOsm/kg and venous lactate 12.3 mmol/L. A urine toxicology screen was negative for amphetamines, barbiturates, benzodiazepines, cocaine, methadone, opiates, phencyclidine, cannabionoids, and tricyclic antidepressants. Blood alcohol, acetaminophen, and salicylate levels were negative. A head computed tomography (CT) was obtained and revealed multiple areas of intracranial hemorrhage in the left temporal and bilateral cerebellar regions. Additionally there was subarachnoid hemorrhage in the left frontal lobe and right posterior frontal lobe (Figure). CT angiography was normal without aneurysm. CT of the chest, abdomen, and pelvis was significant only for diffuse mild dilation of the small bowel and marked fluid content of the entire GI tract.

Figure.

A, B and C. Non contrast CT head demonstrating left temporal and right cerebellar hemorrhages.

While in the ED, the patient received 2L normal saline and intravenous potassium replacement. Neurosurgery was consulted but did not recommend any surgical intervention. He was admitted to the intensive care unit where he continued to receive IV normal saline and electrolyte repletion. The patient's mental status improved to his baseline over the next 24 hours and he was able to endorse that he had consumed an entire box of baking soda (net wt 16oz/454g). His estimated sodium burden was 5,403mEq. A repeat head CT showed stable intracranial hemorrhages. He denied suicidal ideation and after evaluation, psychiatry deemed the patient safe for discharge. He was discharged on hospital day 4 at which time he had a non-focal neurologic exam.

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