Salicylate Toxicity Clinical Presentation

  • Author: Muhammad Waseem, MD; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Oct 27, 2011
 

History

If aspirin usage is suspected, direct questioning is useful. Many patients do not list aspirin or other OTC aspirin-containing products because they may not consider such products as medications. When possible, elicit the following information:

  • Type of salicylate
  • Amount
  • Approximate time of ingestion
  • Possibility of long-term ingestion
  • Potential co-ingestants
  • Presence of other medical conditions (eg, cardiac, renal diseases)

The presence of tinnitus is a clue for salicylate ingestion. Tachypnea, tachycardia, and elevated temperature can be detected by evaluating vital signs. Treatment should not be withheld in symptomatic patients because of pending serum level tests.

The patient who presents with an acute, witnessed, or intentional overdose usually has a history that the physician can directly obtain. Eliciting a history of a chronic overdose in geriatric or psychiatric patients often is harder to accomplish. Thus, diagnosis can be more difficult in these patient populations.

The chronic ingestion of salicylates may produce the appearance of anxiety with its associated tachypnea, diaphoresis, difficulty concentrating, and hallucinations; agitated delirium also may be observed. Elderly individuals may present with deterioration in functional status or with concerns of pneumonia, owing to the presence of tachypnea and fever.

Patients with underlying psychiatric illness may present with symptoms suggestive of an exacerbation of their underlying psychiatric illness (eg, mania, psychosis).

Next

Physical Examination

Pulmonary

Pulmonary symptoms and signs of salicylate poisoning include the following:

  • Hyperventilation (common)
  • Hyperpnea
  • Severe dyspnea due to noncardiogenic pulmonary edema
  • Respiratory arrest
  • Apnea
  • Fever and dyspnea due to aspiration pneumonitis

Auditory

Auditory symptoms caused by the ototoxicity of salicylate poisoning include the following:

  • Decreased hearing
  • Deafness
  • Tinnitus

Tinnitus is commonly encountered when serum salicylate concentrations exceed 30 mg/dL. Although the presence of tinnitus is not a very specific or sensitive clinical effect of salicylate poisoning., it can be a very useful early sign of salicylate toxicity given the right clinical setting.

Cardiovascular

Cardiovascular symptoms of salicylate poisoning include the following:

  • Tachycardia, generally with minimal hemodynamic or clinical significance
  • Hypotension
  • Dysrhythmias - Eg, ventricular tachycardia, ventricular fibrillation, multiple premature ventricular contractions
  • Asystole - With severe intoxication
  • Electrocardiogram (ECG) abnormalities - Eg, U waves, flattened T waves, QT prolongation; may reflect hypokalemia
  • Sudden hemodynamic deterioration secondary to respiratory depression

Respiratory depression limits the respiratory alkalosis and causes an increase in the nonionized portion of salicylate. The nonionized salicylate enters cells and crosses the blood-brain barrier much more readily, causing much higher levels of salicylate in brain tissue, leading to severe CNS toxicity.

Neurologic

Neurologic symptoms, signs, and manifestations of salicylate poisoning include the following:

  • CNS depression, with manifestations ranging from somnolence and lethargy to seizures and coma
  • Tremor
  • Blurring of vision
  • Seizures
  • Cerebral edema - With severe intoxication
  • Encephalopathy

Encephalopathic changes may include irritability, confusion, hyperactivity, and hallucinations. These clinical effects are usually associated with severe cases.

Gastrointestinal

GI symptoms, signs, and manifestations of salicylate poisoning include the following:

  • Nausea and vomiting, with are common
  • Epigastric pain
  • GI hemorrhage - More common with chronic intoxication
  • Intestinal perforation
  • Pancreatitis
  • Hepatitis - Generally in chronic toxicity; rare in acute toxicity

Genitourinary

Genitourinary symptoms, signs, and manifestations of salicylate poisoning include the following:

  • Acute renal failure is an uncommon complication of salicylate toxicity
  • Renal failure may be secondary to multisystem organ failure
  • Case reports have documented the presence of albuminuria

Hematologic

Hematologic effects may include prolongation of the prothrombin and bleeding times and decreased platelet adhesiveness. Disseminated intravascular coagulation (DIC) may be noted with multisystem organ failure in association with chronic salicylate toxicity.

Dermatologic

Contact dermatitis may develop from topical application. Diaphoresis is a common sign in patients with salicylate toxicity.

Electrolytic

Electrolyte-associated symptoms, signs, and manifestations of salicylate poisoning include the following:

  • Dehydration
  • Hypocalcemia
  • Acidemia
  • Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
  • Hypokalemia

Hypokalemia may be a severe iatrogenic complication in patients treated with urinary alkalization, if sufficient potassium supplementation is not provided.

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Contributor Information and Disclosures
Author

Muhammad Waseem, MD  Associate Professor of Emergency Medicine in Clinical Pediatrics, Weill Medical College of Cornell University; Consulting Staff, Department of Pediatrics, Bronx Lebanon Hospital; Consulting Staff, Department of Emergency Medicine, Lincoln Medical and Mental Health Center

Muhammad Waseem, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Muhammad Aslam, MD  Instructor in Pediatrics, Harvard Medical School; Staff Physician, Department of Medicine, Division of Newborn Medicine, Children's Hospital Boston

Muhammad Aslam, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Medical Association, Massachusetts Medical Society, and Southern Medical Association

Disclosure: Nothing to disclose.

Joel R Gernsheimer, MD, FACEP  Visiting Associate Professor, Department of Emergency Medicine, Attending Physician and Director of Geriatric Emergency Medicine, State University of New York Downstate Medical Center

Joel R Gernsheimer, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians and American Geriatrics Society

Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Chair, Department of Emergency Medicine, Director of Medical Toxicology, Allegheny General Hospital; Associate Professor, Department of Emergency Medicine, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Lance W Kreplick, MD, FAAEM, MMM Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC

Lance W Kreplick, MD, FAAEM, MMM, is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives

Disclosure: Nothing to disclose.

Michael E Mullins, MD Assistant Professor, Division of Emergency Medicine, Washington University in St Louis School of Medicine; Attending Physician, Emergency Department, Barnes-Jewish Hospital

Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Emergency Physicians

Disclosure: Johnson & Johnson stock ownership None; Savient Pharmaceuticals stock ownership None

Mark S Slabinski, MD, FACEP, FAAEM Vice President, EMP Medical Group

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut School of Medicine, Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Additional Contributors

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Chair, Department of Emergency Medicine, Director of Medical Toxicology, Allegheny General Hospital; Associate Professor, Department of Emergency Medicine, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Lance W Kreplick, MD, FAAEM, MMM Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC

Lance W Kreplick, MD, FAAEM, MMM, is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives

Disclosure: Nothing to disclose.

Michael E Mullins, MD Assistant Professor, Division of Emergency Medicine, Washington University in St Louis School of Medicine; Attending Physician, Emergency Department, Barnes-Jewish Hospital

Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Emergency Physicians

Disclosure: Johnson & Johnson stock ownership None; Savient Pharmaceuticals stock ownership None

Mark S Slabinski, MD, FACEP, FAAEM Vice President, EMP Medical Group

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut School of Medicine, Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References

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  9. Rauschka H, Aboul-Enein F, Bauer J, Nobis H, Lassmann H, Schmidbauer M. Acute cerebral white matter damage in lethal salicylate intoxication. Neurotoxicology. Jan 2007;28(1):33-7. [Medline].

  10. [Guideline] Chyka PA, Erdman AR, Christianson G, Wax PM, Booze LL, Manoguerra AS, et al. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(2):95-131. [Medline].

  11. Kirshenbaum LA, Mathews SC, Sitar DS, Tenenbein M. Does multiple-dose charcoal therapy enhance salicylate excretion?. Arch Intern Med. Jun 1990;150(6):1281-3. [Medline].

  12. Kirshenbaum LA, Mathews SC, Sitar DS, Tenenbein M. Whole-bowel irrigation versus activated charcoal in sorbitol for the ingestion of modified-release pharmaceuticals. Clin Pharmacol Ther. Sep 1989;46(3):264-71. [Medline].

  13. Proudfoot AT, Krenzelok EP, Brent J, Vale JA. Does urine alkalinization increase salicylate elimination? If so, why?. Toxicol Rev. 2003;22(3):129-36. [Medline].

 
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