Salicylate Toxicity Medication

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

Medication Summary

No specific antidote for salicylate poisoning is available. Therapy is focused on immediate resuscitation, correction of volume depletion and metabolic derangement, GI tract decontamination, and reduction of the body's salicylate burden. Early consultation with a medical toxicologist is prudent.

As previously mentioned, initial treatment should include the use of oral activated charcoal, especially if the patient presents within 1 hour of ingestion.

In a study, whole bowel irrigation (WBI) with polyethylene glycol was found to be more effective than single-dose activated charcoal in reducing salicylate absorption.[12] When enteric-coated aspirin has been ingested or when salicylate levels do not decrease despite treatment with charcoal, WBI should probably be used in addition to charcoal therapy.

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Antidotes, Other

Class Summary

Consider activated charcoal decontamination in any patient who presents within 4 hours of ingestion. Activated charcoal is used for drug absorption and may be all that is required in mild to moderate toxicity. Activated charcoal is not absorbed and is excreted entirely through the GI tract.

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Activated charcoal (Actidose-Aqua, Char-Caps, Kerr Insta-Char)

 

Activated charcoal can limit further gut absorption by binding to available salicylate. This is effective for the regular and sustained-release preparation. No convincing data support the use of repeated doses of activated charcoal in salicylate toxicity. Some authorities recommend repeated doses of activated charcoal to enhance elimination.

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Laxatives, Osmotic

Class Summary

Laxatives with strong osmotic effects that cause cathartic actions to empty the bowel may be useful in this setting.

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Polyethylene glycol (Miralax, Dulcolax Balance)

 

Polyethylene glycol is a laxative with strong electrolyte and osmotic effects that has cathartic actions in the GI tract. Consider WBI when sustained-release products are involved. Remember that this agent does not adsorb anything but instead merely pushes things through the GI tract at a faster rate.

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Urinary Alkalinizing Agents

Class Summary

Sodium bicarbonate is used as a gastric, systemic, and urinary alkalinizer and has been administered in the treatment of acidosis resulting from metabolic and respiratory causes. It also increases renal clearance of acidic drugs. Alkalization of the urine enhances elimination of salicylates through ion trapping in the renal tubules.

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Sodium bicarbonate

 

Constant infusion of sodium bicarbonate produces urinary alkalization if the serum potassium is adequate (typically, >4.5 mEq/L). Urinary alkalization promotes the excretion of salicylate.

If the serum potassium level is low or in the lower end of the reference range (eg, < 4.5 mEq/L), hydrogen ions, instead of potassium ions, follow bicarbonate ions into the urine. Hence, the urine may remain acidic during bicarbonate infusion without potassium repletion.

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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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  2. Lewis TV, Badillo R, Schaeffer S, Hagemann TM, McGoodwin L. Salicylate toxicity associated with administration of Percy medicine in an infant. Pharmacotherapy. Mar 2006;26(3):403-9. [Medline].

  3. Hamdan JA, Manasra K, Ahmed M. Salicylate-induced hepatitis in rheumatic fever. Am J Dis Child. May 1985;139(5):453-5. [Medline].

  4. Herres J, Ryan D, Salzman M. Delayed salicylate toxicity with undetectable initial levels after large-dose aspirin ingestion. Am J Emerg Med. Nov 2009;27(9):1173.e1-3. [Medline].

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

  6. Rumack BH, Matthew H. Acetaminophen poisoning and toxicity. Pediatrics. Jun 1975;55(6):871-6. [Medline].

  7. Pearlman BL, Gambhir R. Salicylate intoxication: a clinical review. Postgrad Med. Jul 2009;121(4):162-8. [Medline].

  8. Kuzak N, Brubacher JR, Kennedy JR. Reversal of salicylate-induced euglycemic delirium with dextrose. Clin Toxicol (Phila). Jun-Aug 2007;45(5):526-9. [Medline].

  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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