Salicylate Toxicity MDM

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pt presents with concern for recent ASA overdose.
Airway maintained.

Unlikely intracranial bleed, ischemic CVA, opioid intoxication, sepsis, hypothyroidism.

Workup: POC glucose, CBC, BMP, LFTs, PT/INR, 4 hour APAP level, salicylate level
ECG: Normal Sinus Rhythm. No overt ischemic findings and no prolongation of QTc or QRS intervals.

Findings:  Salicylate level <100mg/mL on 2 consecutive checks over >1 hour

Consults: Will consult psychiatry for potential LPS hold

Exam and findings most consistent with nontoxic level of ASA intoxication without evidence of other ingestion or other emergent medical pathology.

Disposition: Will admit to psychiatry service

PEARLS

  • Clinical presentation
    • SOB
      • noncardiogenic pulmonary edema (from alteration in the permeability characteristics of the pulmonary capillary membrane)
    • Tinnitus
      • occurs over level of 30-40 (just before treating with urinary alkalinization)
  • Tx
    • First, fluid deficits and acid-base disturbances must be corrected.
      • IVF if no cerebral edema, no pulmonary edema
    • Second, excrete toxin through alkalinization of the urine with bicarb.
      • Sodium bicarbonate
      • NaHCO3 1-2mEq/kg IV bolus; then 3amp bicarb in 1L D5W at 2-3mL/kg/hr. Blood pH goal: 7.5-7.6
      • Check K+ because can lead to life-threatening hypokalemia
        • “to alkalinize the urine you must keep patients from getting hypokalemic
          6.
          Proudfoot A, Krenzelok E, Vale J. Position Paper on urine alkalinization. J Toxicol Clin Toxicol. 2004;42(1):1-26. https://www.ncbi.nlm.nih.gov/pubmed/15083932.
          </div> </div>”>6, cause the kidney will preferentially hold on to potassium and dump a proton, preventing the alkalinization. Keep their K > 4.0 meq/L”
    • HD indications
      • Salicylate toxicity causing noncardiogenic pulmonary edema
        • Should also consider intubation
        • Intubation with a lung-protective ventilation strategy given likely progression to ARDS
          • Low TVs 6-8cc/kg IBW
      • Acute toxicity with ASA level > 100 mg/dL and chronic toxicity > 60 mg/dL

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