SALICYLATE POISONING

Question 1

Approach to the Critically Ill Salicylate Poisoning

Answer 1

Monitor
Oxygen
Vitals
IV Access
ECG / Airway Equipment

AIRWAY / BREATHING

Avoid intubation

If necessary, high minute ventilation must be maintained to ensure serum alkalinity

CIRCULATION

Sodium Bicarbonate 1-2 mEq/kg bolus
THEN
150 mEq in 1 L D5 Water with 40 mEq KCL/l at 1.5-2 x maintenance

GOAL
Serum pH 7.45 - 7.55

Question 2

History and Physical

Answer 2

Salicylate toxicity has no unique physical exam findings

May have the following:

Tachycardia, tachypnea, hyperthermia

Vomiting, Abdominal Pain
(>2.9 mmol / L)

Tinnitus / hearing dysfunction (1.45 - 2.9 mmol / L)

seizures, coma (>6.51 mmol / L)

Non cardiogenic pulmonary edema, ARDS

Diaphoresis

Question 3

Investigations

Answer 3

Accucheck (part of inital assessment)
CBC lytes, creatinine
LFT
INR / PTT
Serum Osolarity
Osmolar gap
VBG
Lactate
Quantitave drug levels: (acetaminophen, salicylates, ethanol)
Urine Tox Screen
Pregnancy test
ECG

CXR (aspiration and pulmonary edema)

Question 4

Management & Goals

Answer 4

Oral activated charcoal (1 g / kg)
within 1 hr

IV Lactated Ringers NOT Normal Saline (may worsen metabolic acidosis)

IV Sodium Bicarbonate:
Bolus 1-2 mEq / kg
THEN
Infusion 150 mEq (3 amps) in 1 L D5W with 40 mEq KCl / L at 1.5 - 2 times maintenance

Goals:
Serum pH 7.45 - 7.55
Urine pH > 7.5

Hemodialysis indications:
CNS involvement
Worsening Metabolic Acidosis
Rising salicylate level despite treatment
Renal failure
Acute Salicylate >6.52 mmol/L
Chronic Salicylate > 4.35 mmol/L
Pulmonary Edema