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Toxicity, Salicylate: Treatment & Medication
Updated: Jul 11, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
- Stabilize the airway, breathing, and circulation.
Emergency Department Care
Therapeutic objectives include cardiopulmonary stabilization, prevention of absorption, correction of fluid deficits, correction of acid-base abnormalities, and enhancement of excretion and elimination.
- Endotracheal intubation may be required for several reasons.
- Ventilatory support in patients with severe hypoxemia from aspirin-induced pulmonary edema
- Maintenance of hyperventilation (as compensation for metabolic acidosis)
- Protection of patients who are too agitated and delirious for central line placement, hemodialysis, and other necessary medical procedures without therapeutic sedation
- Protection of the airway against aspiration during lavage or activated charcoal administration or in obtunded patients who cannot protect their own airway.
- Large-bore vascular access catheters may be required to facilitate emergent hemodialysis.
- Methods to prevent absorption involve emesis, gastric lavage, multidose activated charcoal, and cathartics.
- The use of ipecac syrup is controversial and many studies indicate that it does not alter clinical outcome. It is most effective if given within 30 minutes of ingestion; however, it is relatively contraindicated in the presence of a severe aspirin ingestion because of the risk of seizures from aspirin.
- Gastric lavage may be beneficial, unless contraindicated, up to 60 minutes after salicylate ingestion. Warmed (38°C) isotonic sodium chloride solution may be used. Protect the airway before gastric lavage.
- Administer activated charcoal unless contraindications are present. Current literature does not support the administration of multidose activated charcoal. A cathartic agent may be given with the first charcoal dose; however, repeat cathartic dosing generally should be avoided because of concern over resultant electrolyte imbalances.
- Provide treatment for correction of fluid deficits and enhancement of excretion and elimination
- Administer lactated Ringer or isotonic sodium chloride solution for volume expansion at 10-20 cc/kg/h until a 1-1.5-cc/kg/h urine flow is established.
- Provide maintenance fluids to maintain urinary alkalinization.
- Forced diuresis is not recommended.
- The greater the urine flow, the more difficult it is to alkalinize the urine.
- Be cautious of excessive fluid volumes in cases of salicylate-induced pulmonary edema.
- Perform urinary alkalinization for symptomatic patients and patients with rising salicylate levels or acid-base abnormalities. Consider this treatment if the salicylate level is higher than 35 mg/dL.
- One method to initiate urinary alkalinization uses a single IV bolus of NaHCO 3 at 1-2 mEq/kg. Follow this with a constant infusion of D5W with NaHCO 3 100-150 mEq/L and KCl 20-40 mEq/L at 1.5-2.5 mL/kg/h to produce a urine flow of 0.5-1 mL/kg/h. Closely monitor the serum electrolytes and urine pH, and maintain the urinary pH between 7.5-8.
- The urinary excretion of salicylic acid is dependent upon hydrogen ion gradients, which are, in turn, dependent on adequate serum potassium. Alkaline urine facilitates salicylate ion trapping and excretion but can only be accomplished if adequate potassium is present.
- Monitor glucose levels closely. Initial hyperglycemia may give way to hypoglycemia and worsening CNS symptoms. Tissue glucose levels may be lower than plasma glucose levels.
Consultations
Consult with the regional poison control center or a local medical toxicologist for additional information and patient care recommendations. Consultation with nephrology department personnel is required if hemodialysis is indicated. This decision should be made in conjunction with the medical toxicologist.
- Hemodialysis is the best method for enhanced elimination. Advantages of hemodialysis are increased salicylate clearance, correction of acid-base disturbances, and correction of fluid and electrolyte abnormalities.
- Recommendations for hemodialysis include the following:
- Severe manifestations of intoxication (eg, persistent neurological symptoms, pulmonary edema, renal failure)
- Refractory or profound acidosis (ie, progressive deterioration despite conservative efforts)
- Serum levels higher than 100 mg/dL after acute overdose or serum levels higher than 40-50 mg/dL in chronic salicylism
Medication
Drug therapy includes activated charcoal, sodium bicarbonate, and polyethylene glycol solution.
GI decontaminants
Limits absorption of ingested substance.
Activated charcoal (Liqui-Char)
Emergency treatment in poisoning caused by drugs and chemicals. Network of pores present in activated charcoal adsorbs 100-1000 mg of drug per gram of charcoal. Does not dissolve in water.
For maximum effect, administer within 30 min of ingesting poison.
Adult
1 g/kg PO; may repeat in 2-4 h at one-half original dose
Pediatric
Administer as in adults (typical 12.5-25 g)
<2 years: Cathartic not recommended
May inactivate ipecac syrup if used concomitantly; effectiveness of other medications decreases with coadministration; do not mix with sherbet, milk, or ice cream (decreases adsorption)
Documented hypersensitivity; poisoning or overdose of mineral acids and alkalies; unprotected airway with absent gag reflex
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not very effective in poisonings of ethanol, methanol, and iron salts; induce emesis before administration; after emesis with ipecac syrup, patient may not tolerate activated charcoal for 1-2 h; can administer in early stages of gastric lavage; without sorbitol, gastric lavage returns are black; protect airway in patients with depressed level of consciousness; if using multiple dose charcoal, monitor for presence of bowel sounds to minimize risk of charcoal ileus and vomiting with subsequent pulmonary aspiration
Polyethylene glycol (GoLYTELY, Colyte)
Laxative with strong electrolyte and osmotic effects that has cathartic actions in GI tract. Consider whole bowel irrigation when sustained-release products are involved. Remember that this agent does not adsorb anything but merely pushes things through the GI tract at a faster rate.
Adult
2 L/h PO/NG
Pediatric
20 mL/kg/h PO/NG
Reduces effectiveness and absorption of oral medications
Documented hypersensitivity; colitis, megacolon, bowel perforation, gastric retention or GI obstruction; unprotected airway
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in ulcerative colitis, hot loop polypectomy; caution in obtunded, comatose, or seizing patients
Alkalinizing agent
Alkalinization of the urine enhances elimination of salicylates through ion trapping in the renal tubules.
Sodium bicarbonate (Neut)
Alkalinizes urine, causing excretion of salicylate to increase.
Adult
1-2 mEq/kg IV push, then begin infusion; add 2-3 amps (available in 44 mEq/amp and 50 mEq/amp) of sodium bicarbonate and KCl 20-40 mEq/L in 1 L D5W; infuse at 1.5-2.5 mL/kg/h
Pediatric
Administer as in adults
Urinary alkalinization, induced by increased sodium bicarbonate concentrations, may cause decreased levels of lithium, tetracyclines, chlorpropamide, methotrexate, and salicylates; increases levels of amphetamines pseudoephedrine, flecainide, anorexiants, mecamylamine, ephedrine, quinidine, and quinine
Documented hypersensitivity; alkalosis, hypernatremia, hypocalcemia, severe pulmonary edema, and unknown abdominal pain
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Only use to treat documented metabolic acidosis and hyperkalemia-induced cardiac arrest; can cause alkalosis, decreased plasma potassium, hypocalcemia and hypernatremia (ensure serum pH does not exceed 7.55); caution in electrolyte imbalances such as CHF, cirrhosis, edema, corticosteroid use, or renal failure; when administering, avoid extravasation because can cause tissue necrosis
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| Differential Diagnoses & Workup: Toxicity, Salicylate |
 Treatment & Medication: Toxicity, Salicylate |
| Follow-up: Toxicity, Salicylate |
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References
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Temple AR. Acute and chronic effects of aspirin toxicity and their treatment. Arch Intern Med. Feb 23 1981;141(3 Spec No):364-9. [Medline].
Further Reading
Keywords
aspirin overdose, aspirin, aspirin poisoning, aspirin ingestion, salicylate toxicity, salicylate ingestion, salicylate overdose, salicylate poisoning
