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salicylate toxicity

Etiology: - aspirin ingestion is the most cause of salicylate toxicity - ingestion of > 10 grams of aspirin (adults) - cutaneous exposure to salicylate-containing topical agents such as oil of wintergreen Pathology: - cerebral edema - acute lung injury - non-cardiogenic pulmonary edema - hepatic toxicity - respiratory alkalosis - more with severe intoxication, anion gap metabolic acidosis - lactic acidosis, ketoacidosis Clinical manifestations: 1) initially respiratory alkalosis with - tinnitus - confusion - tachypnea - low-grade fever occasionally - nausea/vomiting from gastric mucosal toxicity 2) later metabolic acidosis 3) CNS disturbance with EEG abnormalities Laboratory: - arterial blood gas - respiratory alkalosis progresses to metabolic acidosis - chem8 (calculate anion gap) - serum Na+ - serum K+ - serum bicarbonate - serum chloride - plasma osmolality & osmolal gap (none) [1] - salicylate in serum/plasma - international normalized ratio (INR) Complications: - fatal brainstem herniation Management: 1) activated charcoal 50-100 g if presenting within 1 hour of ingestion; multiple doses may be useful 2) alkaline diuresis for patients with plasma salicylate levels > 40 mg/dL a) 150 meq (3 ampules) of NaHCO3 in 1 liter of D5W at 10-15 mL/kg/hour until urine flow is achieved b) maintenance 2-3 mL/kg/hour c) monitor urine output, urine pH (target pH=7-8; > 7.5 [1]), serum K+ d) 40 meq KCl over 4-5 hours - successful alkaline diuresis requires simultaneous administration of KCl e) mitigates CNS toxicity f) do not use acetazolamide (increases CNS salicylate toxicity) 3) hemodialysis for cerebral edema, pulmonary edema, anion gap metabolic acidosis or plasma salicylate > 80-100 mg/dL 4) hyperventilate patients requiring endotracheal intubation 5) treat altered mental status with IV glucose (despite normal serum glucose) - 100 mL of 50% glucose 6) vitamin K for increased INR

Related

salicylate

General

toxicity; poisoning; overdose

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018.
  2. Pearlman BL, Gambhir R. Salicylate intoxication: a clinical review. Postgrad Med. 2009 Jul;121(4):162-8. PMID: 19641282
  3. Bora K, Aaron C. Pitfalls in salicylate toxicity. Am J Emerg Med. 2010 Mar;28(3):383-4. PMID: 20223401
  4. Klig KE, Sharma A, Skolnik AB Case 26-2014 - A 21-Month-Old Boy with Lethargy, Respiratory Distress, and Abdominal Distension. N Engl J Med 2014; 371:767-773. August 21, 2014 PMID: 25140963 http://www.nejm.org/doi/full/10.1056/NEJMcpc1400834
  5. Palmer BF, Clegg DJ Salicylate Toxicity. N Engl J Med 2020; 382:2544-2555 June 25, 2020 PMID: 32579814 https://www.nejm.org/doi/full/10.1056/NEJMra2010852?query=aging-geriatrics
  6. O'Malley GF. Emergency department management of the salicylate-poisoned patient. Emerg Med Clin North Am 2007 May; 25:333 PMID: 17482023
  7. Pearlman BL, Gambhir R. Salicylate intoxication: a clinical review. Postgrad Med 2009 Jul; 121:162. PMID: 19641282