Lithium poisoning: Rapid overview of emergency management

To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links).

Clinical presentation

Acute and acute-on-chronic toxicity often presents with nausea, vomiting, and diarrhea; neurologic findings are a late development.

Chronic poisoning often presents with neurologic findings: sluggishness, ataxia, confusion, agitation, and/or neuromuscular excitability.

Severe toxicity can cause seizures, nonconvulsive status epilepticus, or encephalopathy.

In older patients, toxicity may be the result of hypovolemia or decline in kidney function.

History and physical examination

Determine nature of ingestion (eg, acute, acute-on-chronic, chronic, suicide attempt), including whether ingested drug is immediate or extended release.

Inquire about recent illness causing hypovolemia (eg, vomiting, diarrhea, fever, anorexia, diuretics, or laxatives).

Assess for signs of hypovolemia.

Perform a focused neurologic examination; look for alterations in mentation, ataxia, and neuromuscular excitability (eg, tremors, myoclonus).

Diagnostic evaluation

Obtain serum lithium concentration upon presentation and repeat every 4 hours during initial management until <1 mEq/L; therapeutic range 0.8 to 1.2 mEq/L (mmol/L); serum concentration may not correlate with clinical severity.

Obtain the following blood tests: fingerstick glucose, electrolytes (including Na, K, Cl, HCO₃), creatinine and BUN, complete blood count (hemoglobin, platelets, white blood cells), acetaminophen and salicylate concentrations (with suicide attempt or possible co-ingestion), pregnancy test in female patients of childbearing age, and thyrotropin (TSH).

Obtain an electrocardiogram.

Management

Assess and stabilize airway, breathing, and circulation.

Restore sodium and water balance:

Initiate IV fluids with isotonic saline, initially until euvolemic, followed by twice maintenance rate. The goal is to maintain adequate urine output (>1.5 to 3 ml/kg per hour) but depends on fluid status and cardiac function.
Monitor serum sodium closely (every 4 to 6 hours, can obtain with serial lithium concentrations) in patients with concern for lithium-induced nephrogenic diabetes insipidus.

Give whole-bowel irrigation with PEG solution to awake, asymptomatic patients (no airway concern or aspiration risk) or intubated patients who present within 4 hours after an ingestion of more than 10 to 15 tablets of extended-release lithium or within 1 hour of large ingestion of immediate-release lithium. The dose of PEG is 500 mL to 2 L per hour via nasogastric tube until the rectal effluent is clear.

Obtain nephrology consultation early for significant lithium toxicity prior to the development of obvious indications for hemodialysis.

Perform hemodialysis for the following indications:

Symptoms of severe lithium toxicity (eg, seizures, altered mental status, hypotension that does not resolve quickly with IV fluids, rigidity, hypertonicity, myoclonus, cardiopulmonary collapse, or life-threatening dysrhythmia) irrespective of the lithium concentration.
Serum lithium concentration >4 mEq/L (4 mmol/L) in patient with impaired kidney function (eGFR <45 mL/min, serum creatinine ≥2 mg/dL in adults, serum creatinine ≥1.5 mg/dL in older adult or patient who has low muscle, doubling of baseline serum creatinine [if known], serum creatinine greater than 2 times upper limit of normal for age and sex in child).
Serum lithium concentration >5 mEq/L (or 5 mmol/L).
If the expected time to obtain a serum lithium concentration <1 mEq/L with optimal management is more than 36 hours, in patients with symptoms suggestive of chronic lithium toxicity, an approximate guideline is a serum lithium concentration >1.8 mEq/L if eGFR <50 mL/min and serum lithium concentration >2.2 mEq/L if eGFR >50 mL/min.

BUN: blood urea nitrogen; IV: intravenous; PEG: polyethylene glycol; eGFR: estimated glomerular filtration rate.

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Lithium poisoning: Rapid overview of emergency management