Daily Bolus of LR: Salicylate toxicity

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September 8, 2011 by dailybolusoflr

Salicylate/Aspirin Toxicity



·         Seen in intentional overdose as well as accidental chronic overdose, usually in elderly patients


·         Salicylates act directly on the respiratory center of the brainstem and cause hyperventilation- respiratory alkalosis seen initially

·         Salicylate, as a weak acid, interferes with the Krebs cycle and generates lactate – metabolic acidosis develops early but is seen later as the respiratory alkalosis predominates initially

·         This mixed metabolic picture (with academia, metabolic acidosis and respiratory alkalosis) is the “hallmark” of life threatening salicylate overdose


Clinical Presentation

·         Nausea and vomiting

·         Tinnitus and/or hearing loss

·         Hyperventilation

·         Hyperthermia

o   Severe hyperthermia is often viewed as a pre-terminal event as it signifies uncoupling of oxidative phosphorylation

·         AMS (wide spectrum)

·         Non-cardiogenic pulmonary edema (less common)

o   Higher risk in older patients, higher levels, those with neurologic symptoms

·         Renal failure


Evaluation and Treatment

·         Salicylate level

o   A falling level may not actually indicate elimination but rather re-distribution into the body tissue, especially the CNS.

o   Patients with persistent acidemia with falling levels should still be considered to be acutely poisoned and managed as such

§  Acidosis allows salicylate to unbind from serum proteins and enter the CNS resulting in increased toxicity

o   CSF levels are said to correlate better with actual peak serum levels

·         Basic labs and ABG (may see alterations in glucose and/or hypokalemia)

·         Treatments are supportive: lyte repletion, charcoal, hemodialysis and alkalinization of the blood/urine

o   HD- possibly based on a level over 100mg/dL as well as for clinical s/sx

o   Charcoal binds salicylate well

o   Alkalinization should be accomplished with sodium bicarbonate to a pH of 7.45-7.55.  This traps salicylates out of the CNS and allows renal excretion.   It should be mixed in D5W.


Ref: Goldfrank’s Toxicology

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