Salicylate toxicity (Aspirin toxicity)

General principles ^[1][2]

Initial assessment and airway management

• Stabilize the patient.
• Assess the severity of salicylate toxicity (see salicylate toxicity severity above).
• For symptomatic patients: Consult ICU, nephrology, and toxicology.
• Evaluate the need for intubation but avoid intubation, if possible.
  • If intubation is necessary
    • Administer bicarbonate prior to intubation
    • Maximize minute ventilation (e.g., at least 8–10 mL/kg/breath)

Indications for intubation in salicylate toxicity

• Deteriorating mental state
• Seizures
• ARDS
• Hypoventilation (e.g., hypercarbia)

Indications for hemodialysis in salicylate toxicity ^[3]

• Serum salicylates > 100 mg/dL (> 90 mg/dL if renal function impaired)
• Serum salicylates > 90 mg/dL (> 80 mg/dL if renal function impaired) or arterial pH ≤ 7.2 despite supportive care
• Altered mental status
• Hypoxemia requiring supplemental O₂

Intubating patients with salicylate toxicity is dangerous! If intubation is required, extra care should be taken to maximize minute ventilation, as there is a high risk of worsening acidosis and death.

Salicylate combinations with other substances (like opioids) can lead to mixed intoxications that require specific management (e.g., naloxone).

Gastric decontamination ^[1][4]

• Considerations for gastric lavage
  • The ingested aspirin dose is known to be > 500 mg/kg.
  • Ingestion occurred < 1 hour prior to presentation.
• Considerations for oral activated charcoal
  • The patient must have a secure airway (i.e., is awake and alert or is intubated with an orogastric tube).
  • Timing of ingestion: There are no specific recommendations. ^[4]
    • 2–4 hours of known ingestion: Giving at least one dose is most likely beneficial.
    • Within 4–24 hours of known ingestion: may be beneficial in some patients (e.g., ingestion of a large amount, severe toxicity)

Fluid and acid-base management ^[1]

• Fluid resuscitation
  • Preferred fluids: LR and/or 5% dextrose
  • Isotonic bicarbonate solutions, if alkalinization is required (see below)
  • Avoid normal saline, as it can aggravate acidosis.
  • Add IV dextrose even if blood glucose is normal to prevent cerebral hypoglycemia.
• Alkalinization of serum and urine with IV sodium bicarbonate ^[2][1]
  • Indications: any symptomatic patient, or if serum salicylates > 60 mg/dL
  • Bicarbonate dosage
    • Consider bicarbonate loading dose , especially if arterial pH < 7.3 or patient requires intubation.
    • Continuous bicarbonate in D5W to achieve and maintain urine alkalization ^[1][2]
    • Targets ^[1]
      • Serum pH 7.5–7.55
      • Urine pH 7.5–8.5
      • Urine output: 2–3 mL/kg/hour ^[2]
      • Serum potassium: 4–4.5 mEq/L

Monitoring and additional concerns

• Repeat labs every 2 hours.
  • Blood glucose, BMP, ABG
  • Serum salicylates (until consistently < 40 mg/dL)
• ICU level of care
• Continuous cardiac monitoring, continuous pulse oximetry, frequent neurological checks
• Evaluate and treat suicidal ideation.