eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Lithium: Differential Diagnoses & Workup

Author: David C Lee, MD, Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School
Coauthor(s): Amit Gupta, MD, Fellow, Department of Toxicology, North Shore Hospital
Contributor Information and Disclosures

Updated: Mar 24, 2009

Differential Diagnoses

Delirium, Dementia, and Amnesia
Toxicity, Anticholinergic
Depression and Suicide
Toxicity, Heavy Metals
Hypoglycemia
Toxicity, Mercury
Neuroleptic Malignant Syndrome
Toxicity, Neuroleptic Agents
Schizophrenia
Toxicity, Organophosphate and Carbamate
Stroke, Ischemic
Toxicity, Sedative-Hypnotics
Toxicity, Alcohols

Workup

Laboratory Studies

  • Therapeutic drug monitoring is readily available in most settings, and symptomatic patients should have their lithium levels measured. levels may not correlate with clinical symptoms due to the kinetic profile of lithium. 
    • A repeat level should be checked several hours later after intravenous hydration to disclose any trend.
    • Serial levels may be warranted in cases of sustained-release tablets.

  • The sample must be sent in a lithium-free tube, as falsely elevated levels have been obtained in plasma samples obtained in lithium-containing tubes. 
  • Urinalysis, electrolyte levels, and renal function should also be sent. A low anion gap or a low urine specific gravity may suggest lithium toxicity due to sodium loss.
  • Thyroid function panel may also be considered in patients presenting with symptoms suggestive of hypothyroidism. 
  • Co-ingestants should also be considered in cases of intentional overdose. 
  • Acetaminophen level should be obtained in every patient suspected of intentional overdose.
  • Lumbar puncture should be considered in patients with altered mental status and suspicion of CNS infection.

Imaging Studies

  • Consider a CT scan of the head in individuals with severe movement disorders, seizures, stupor, or coma. CT scan may be needed to rule out other etiologies and to examine for trauma secondary to intoxication.

Other Tests

  • Electrocardiography
    • Chronic lithium toxicity is frequently associated with nonspecific and diffuse depressed ST segments and T-wave inversion unassociated with symptoms or significant sequelae.
    • Lithium intoxication may result in dysrhythmias, including complete heart block.
    • Serious cardiac toxicity is uncommon and generally only occurs in individuals with underlying heart disease.

More on Toxicity, Lithium

Overview: Toxicity, Lithium
Differential Diagnoses & Workup: Toxicity, Lithium
Treatment & Medication: Toxicity, Lithium
Follow-up: Toxicity, Lithium
References
[ CLOSE WINDOW ]

References

  1. Linakis JG, Savitt DL, Wu TY, Lockhart GR, Lacouture PG. Use of sodium polystyrene sulfonate for reduction of plasma lithium concentrations after chronic lithium dosing in mice. J Toxicol Clin Toxicol. 1998;36(4):309-13. [Medline].

  2. Menghini VV, Albright RC Jr. Treatment of lithium intoxication with continuous venovenous hemodiafiltration. Am J Kidney Dis. Sep 2000;36(3):E21. [Medline].

  3. van Bommel EF, Kalmeijer MD, Ponssen HH. Treatment of life-threatening lithium toxicity with high-volume continuous venovenous hemofiltration. Am J Nephrol. Sep-Oct 2000;20(5):408-11. [Medline].

  4. Alexander MP, Farag YM, Mittal BV, Rennke HG, Singh AK. Lithium toxicity: a double-edged sword. Kidney Int. Jan 2008;73(2):233-7. [Medline].

  5. Aral H, Vecchio-Sadus A. Toxicity of lithium to humans and the environment--a literature review. Ecotoxicol Environ Saf. Jul 2008;70(3):349-56. [Medline].

  6. Burkhart, K. Lithium. In: Rosen's Emergency Medicine: Concepts and Clinical Practice. Sixth Edition. Mosby Elsevier; 2006:2442-2444.

  7. Chen KP, Shen WW, Lu ML. Implication of serum concentration monitoring in patients with lithium intoxication. Psychiatry Clin Neurosci. Feb 2004;58(1):25-9. [Medline].

  8. Eyer F, Pfab R, Felgenhauer N, et al. Lithium poisoning: pharmacokinetics and clearance during different therapeutic measures. J Clin Psychopharmacol. Jun 2006;26(3):325-30. [Medline].

  9. Freeman MP, Freeman SA. Lithium: clinical considerations in internal medicine. Am J Med. Jun 2006;119(6):478-81. [Medline].

  10. Giles JJ, Bannigan JG. Tetatogenic and developmental effects of lithium. Curr Pharm Des. 2006;12(12):1531-41.

  11. Gitlin M. Lithium and the kidney: an updated review. Drug Saf. Mar 1999;20(3):231-43. [Medline].

  12. Greller, H. Lithium. In: Goldfrank's Toxicologic Emergencies. Eighth. McGraw-Hill; 2006:1052-1058.

  13. Groleau G. Lithium toxicity. Emerg Med Clin North Am. May 1994;12(2):511-31. [Medline].

  14. Hsu CH, Liu PY, Chen JH, Yeh TL, Tsai HY, Lin LJ. Electrocardiographic abnormalities as predictors for over-range lithium levels. Cardiology. 2005;103(2):101-6. [Medline].

  15. Juurlink DN, Mamdani MM, Kopp A, Rochon PA, Shulman KI, Redelmeier DA. Drug-induced lithium toxicity in the elderly: a population-based study. J Am Geriatr Soc. May 2004;52(5):794-8. [Medline].

  16. Lee DC, Klachko MN. Falsely elevated lithium levels in plasma samples obtained in lithium containing tubes. J Toxicol Clin Toxicol. 1996;34(4):467-9. [Medline].

  17. Ng YW, Tiu SC, Choi KL, Chan FK, Choi CH, Kong PS. Use of lithium in the treatment of thyrotoxicosis. Hong Kong Med J. Aug 2006;12(4):254-9. [Medline].

  18. Rosenqvist M, Bergfeldt L, Aili H, Mathe AA. Sinus node dysfunction during long-term lithium treatment. Br Heart J. Oct 1993;70(4):371-5. [Medline].

  19. Scharman EJ. Methods used to decrease lithium absorption or enhance elimination. J Toxicol Clin Toxicol. 1997;35(6):601-8. [Medline].

  20. Timmer RT, Sands JM. Lithium intoxication. J Am Soc Nephrol. Mar 1999;10(3):666-74. [Medline].

  21. Zimmerman JL. Poisonings and overdoses in the intensive care unit: general and specific management issues. Crit Care Med. Dec 2003;31(12):2794-801. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

lithium toxicity, lithium exposure, lithium overdose, lithium intoxication, chronic lithium therapy, long-term lithium therapy, lithium in the treatment of depressive and bipolar disorders, lithium poisoning, lithium carbonate, Li2 CO3, lithium citrate, Li3 C6 H5 O7 ·4H2 O, treatment of depressive disorders, treatment of bipolar affective disorders, lithium ingestion

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

David C Lee, MD, Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School
David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Amit Gupta, MD, Fellow, Department of Toxicology, North Shore Hospital
Amit Gupta, MD is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

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.

Managing Editor

John G Benitez, MD, MPH, FACMT, FACPM, FAAEM, Associate Professor, Department of Medicine, Clinical Pharmacology Division, Vanderbilt University; Managing Director, Tennessee Poison Center
John G Benitez, MD, MPH, FACMT, FACPM, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.