Version May 2024
| 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 and laboratory features |
| Common: tachypnea, tinnitus, nausea, vomiting, acid-base abnormalities |
| Severe cases: hyperthermia, altered mental status, pulmonary edema |
| Diagnostic evaluation |
| Plasma/serum salicylate concentration, arterial blood gas (ABG), basic electrolytes, BUN and creatinine, urine pH, chest radiograph |
| Repeat salicylate concentration every two hours until it is declining |
| Repeat ABG every two hours until acid-base status stable or improving |
| Treatment |
| Avoid tracheal intubation if at all possible. Reserve intubation for a patient with hypoventilation or requiring airway protection since peri-procedural cardiovascular collapse can occur and post-intubation mechanical ventilation must match the high minute ventilation of the patient prior to intubation. |
| In an agitated patient, avoid applying physical restraints or administering sedative medications since may worsen the metabolic acidosis by impairing respiratory alkalosis. |
| Administer supplemental oxygen as needed |
| Volume resuscitate unless cerebral or pulmonary edema is present |
| Administer multiple doses of activated charcoal (first dose: 1 g/kg orally up to 50 g) |
| Administer supplemental glucose in patients with altered mental status, even if serum glucose concentration is normal: IV dextrose 50 g as 100 mL of 50% dextrose |
| Alkalinize with sodium bicarbonate |
| Bolus therapy: sodium bicarbonate, 1 to 2 mEq/kg (maximum 100 mEq) IV push over 3 to 5 minutes |
| Maintenance therapy: 100 to 150 mEq sodium bicarbonate in 1 L of D5W, run at 250 mL/hour in adults or run at 1.5 to 2 times maintenance in children |
| Correct hypokalemia, hypocalcemia and other electrolyte abnormalities. IV sodium bicarbonate is NOT compatible with calcium salts. |
| Alkalemia (arterial pH up to 7.55) is NOT a contraindication to sodium bicarbonate therapy |
| DO NOT USE ACETAZOLAMIDE TO ALKALINIZE THE URINE |
| Alert nephrology team early in the patient's clinical course; indications for hemodialysis include: |
| Profoundly altered mental status |
| Pulmonary or cerebral edema |
| Renal insufficiency that interferes with salicylate excretion |
| Fluid overload that prevents the administration of sodium bicarbonate |
| A plasma salicylate concentration >100 mg/dL (7.2 mmol/L) in acute ingestion or >60 mg/dL (4.3 mmol/L) in chronic ingestion |
| Clinical deterioration despite aggressive and appropriate supportive care |
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