eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology

Toxicity, Salicylate: Differential Diagnoses & Workup

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
Coauthor(s): Muhammad Aslam, MD, Clinical Fellow, Department of Newborn Medicine, Children's Hospital Boston; Joel R Gernsheimer, MD, Program Director, Department Emergency Medicine, Lincoln Medical and Mental Health Center
Contributor Information and Disclosures

Updated: Feb 12, 2008

Differential Diagnoses

Sepsis

Workup

Laboratory Studies

  • Bedside ferric chloride testing: Qualitative determination for the presence of salicylates can be rapidly performed in the emergency department by adding a few drops of 10% ferric chloride (FeCl3) to 1 mL of urine. If salicylates are present, the solution changes to a brown-purple color. Positive results with the urine ferric chloride test indicate that obtaining a quantitative serum salicylate level is necessary because even the ingestion of a single aspirin tablet can result in a positive test result.
  • ABG: ABG should be obtained to evaluate for the presence of acid-base disturbances. Primary respiratory alkalosis may occur, followed by concomitant primary metabolic acidosis resulting from production of lactic acid, metabolites, and other organic acids. Therefore, the most common abnormality is a mixed acid-base disturbance (a primary respiratory alkalosis plus a primary metabolic acidosis).
  • Salicylate concentration: Initial and serial salicylate levels are important in the evaluation of salicylate toxicity. The absolute level should not detract from the importance of careful and repeated clinical evaluation.
    • Therapeutic range of salicylate is 15-30 mg/dL. Patients are often symptomatic at salicylate concentrations higher than 40-50 mg/dL. Patients with salicylate concentrations approaching or exceeding 100 mg/dL usually have serious or life-threatening toxicity.
    • Caution: Always confirm the units of measurement with the laboratory. Traditional units are milligrams per deciliter; however, many laboratories report salicylate concentrations in milligrams per liter or micrograms per milliliter, both of which differ by a factor of 10 from the traditional units. For example, a salicylate concentration of 100 mg/dL is seriously toxic, but a concentration of 100 mg/L is subtherapeutic. A concentration of 100 mg/L is equal to a concentration of 10 mg/dL.
    • In overdoses, the peak serum concentration may not occur for 4-6 hours. Concentrations obtained before that time may not reflect peak levels. Levels from 15-30 mg/dL are considered to be within therapeutic range. Signs and symptoms of toxicity begin to appear at levels higher than 30 mg/dL. A 6-hour salicylate level higher than 100 mg/dL is considered potentially lethal and is an indication for hemodialysis. Chronic ingestion can increase the half-life to longer than 20 hours.
    • In significant ingestions, serum salicylate levels should be monitored at least every 2 hours until a peak has been reached and then every 4-6 hours until the peak falls into the nontoxic range.
    • Toxicity of salicylates correlates poorly with serum levels, and the levels are less helpful in patients with long-term exposure. Patients with long-term salicylate toxicity may have a level within the therapeutic range (10-20 mg/dL). Serum salicylate levels correlate only moderately with clinical manifestations. In acute ingestion, levels may be high without significant clinical signs, while long-term exposure levels in the high therapeutic range may be associated with significant clinical toxicity.
    • The Done nomogram was formulated in 1960 to assist physicians in predicting the severity of salicylate intoxication based on a serum level and a known time of ingestion. The nomogram was based primarily on previously healthy pediatric patients with acute single-salicylate ingestion. However, clinical application of the nomogram has several limitations. The nomogram is used only to evaluate a single acute ingestion. In contrast to the Rumack-Matthew nomogram,5 the Done nomogram indicates severity of toxicity based on a 6-hour level of non–enteric-coated aspirin rather than the need for antidotal therapy. Currently, the Done nomogram is regarded as not very useful.
  • Other laboratory studies
    • Serum electrolyte renal function studies (BUN and creatinine levels)
    • Serum glucose levels
    • Serum acetaminophen levels
    • Liver function tests
    • Coagulation studies (prothrombin time and activated partial thromboplastin time)
    • Urinalysis

More on Toxicity, Salicylate

Overview: Toxicity, Salicylate
Differential Diagnoses & Workup: Toxicity, Salicylate
Treatment & Medication: Toxicity, Salicylate
Follow-up: Toxicity, Salicylate
References
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References

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Further Reading

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Keywords

salicylate toxicity, salicylic toxicity, aspirin, oil of wintergreen, salicylic acid, salicylate toxicity, salicylate poisoning, salicylate intoxication, aspirin overdose, analgesic overdose, tinnitus, bedside ferric chloride testing, activated charcoal, methyl salicylate, Pepto-Bismol, Ben-Gay, respiratory alkalosis, ketosis, wide anion-gap metabolic acidosis, noncardiogenic pulmonary edema, hypoxia, dehydration, tinnitus, cerebral edema, hyperthermia, pylorospasm, hepatitis, Reye syndrome, hypoprothrombinemia, rhabdomyolysis

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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 and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Muhammad Aslam, MD, Clinical Fellow, Department 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, Program Director, Department Emergency Medicine, Lincoln Medical and Mental Health Center
Joel R Gernsheimer, MD is a member of the following medical societies: American College of Emergency Physicians, American Geriatrics Society, American Heart Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Michael E Mullins, MD, Assistant Professor, Department of Emergency Medicine, Washington University School of Medicine
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

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
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.

 
 
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