Salicylate poisoning

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 12 Aug 2025

Last updated: 22 Mar 2024

Salicylate poisoning is potentially fatal. It can present acutely or indolently with more chronic exposure.

Diagnosis should be considered in any patient presenting with a history of unknown toxin ingestion or exposure, particularly in the presence of an unexplained acid-base disturbance. Early consultation with the local poison control center and/or toxicologist is recommended.

Clinical presentation is more important than salicylate levels in directing therapeutic decisions.

Alkalinization of serum and urine is considered first-line treatment for patients with moderate or severe clinical signs and symptoms. Key to successful alkalinization is aggressive management of hypokalemia.

Emergency hemodialysis is recommended for unstable patients with renal insufficiency, acute respiratory failure, metabolic acidosis refractory to alkalinization, prolonged corrected QT interval, noncardiogenic pulmonary edema, altered mental status, seizures, or salicylate levels >100 mg/dL.

Definition

Salicylate poisoning is the result of ingestion of, or (rarely) topical exposure to, chemicals metabolized to salicylate.[1] Poisoning may occur due to acute or chronic salicylate exposure and is characterized by acid-base disturbances, electrolyte abnormalities, and central nervous system effects.[1] The most common source of salicylate poisoning is aspirin (acetylsalicylic acid), which is rapidly hydrolyzed to salicylate in the gastrointestinal tract, liver, and bloodstream. Acute toxicity may occur after ingestion of a single dose of aspirin or the equivalent of >150 mg/kg or >6.5 g.[2] Chronic poisoning tends to occur as a result of repeated exposure to high-dose aspirin or equivalent (150 mg/kg/day), particularly in people with renal insufficiency.[1]

History and exam

Key diagnostic factors

ingestion of 150 mg/kg or more, or 6.5 g or more, of aspirin or aspirin equivalent
ingestion of methyl salicylate (oil of wintergreen)
ingestion of bismuth subsalicylate
self-harm or suicide attempt
children ages 3 years or younger and adults 70 years or older
unknown toxin ingestion or exposure
abnormal behavior
nausea, vomiting, hematemesis, epigastric pain
fever and diaphoresis
shortness of breath
tachypnea, Kussmaul respirations
tinnitus and/or deafness
malaise and/or dizziness
movement disorders, asterixis, stupor
confusion and/or delirium (irritability, hallucinations)
coma and/or papilledema
seizures
rales plus low oxygen saturation

Full details

Other diagnostic factors

volume depletion
skin rash

Full details

Risk factors

ingestion of 150 mg/kg or more, or 6.5 g or more, of aspirin or aspirin equivalent
ingestion of methyl salicylate (oil of wintergreen)
ingestion of bismuth subsalicylate
history of self-harm or suicide attempt
children ages 3 years or younger and adults 70 years or older

Full details

Diagnostic tests

1st tests to order

ABG
serum electrolyte panel
serum salicylate level
serum BUN and creatinine
serum ketones
blood glucose
CBC
serum LFTs
serum PT, activated PTT, INR
toxicology screen
chest x-ray
ECG

Full details

Tests to consider

echocardiogram
head CT scan
EEG

Full details

Treatment algorithm

ACUTE

asymptomatic: without criteria for hospital referral

asymptomatic: with criteria for hospital referral

symptomatic

Contributors

Authors

Chris Hoyte, MD

Medical Toxicology Fellowship Program Director

Rocky Mountain Poison and Drug Safety

Denver

Professor

Department of Emergency Medicine

University of Colorado School of Medicine

Aurora

Disclosures

CH declares that he has no competing interests.

Eric Lavonas, MD, MS

Attending Physician

Department of Emergency Medicine and Rocky Mountain Poison and Drug Safety

Denver Health

Denver

Professor

Department of Emergency Medicine

University of Colorado School of Medicine

Aurora

Disclosures

EL is an author of a reference cited in this topic.

Acknowledgements

Dr Chris Hoyte and Dr Eric Lavonas would like to gratefully acknowledge Dr Kathryn A. Koch, a previous contributor to this topic. KAK declares that she has no competing interests.

Peer reviewers

Colin A. Graham, MBChB, MPH, MD, FRCSEd, FRCSGlasg, FIMCRCSEd, FCCP, FCEM, FHKCEM, FHKAM

Editor

European Journal of Emergency Medicine

Professor of Emergency Medicine

Chinese University of Hong Kong

Hong Kong

People's Republic of China

Disclosures

CAG is the editor of the European Journal of Emergency Medicine and receives an annual honorarium from Wolters Kluwer Health, the journal's publishers.

Gerald F. O'Malley, DO

Director

Division of Research

Department of Emergency Medicine

Albert Einstein Medical Center

Philadelphia

Disclosures

GFOM declares that he has no competing interests.

Paul Wax, MD

Clinical Professor of Surgery (Emergency Medicine)

University of Texas Southwestern Medical Center

Dallas

Disclosures

PW is an author of a reference cited in this topic.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Palmer BF, Clegg DJ. Salicylate toxicity. N Engl J Med. 2020 Jun 25;382(26):2544-55. Abstract

Chyka PA, Erdman AR, Christianson G, et al. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(2):95-131.Full text Abstract

American College of Medical Toxicology. Guidance document: management priorities in salicylate toxicity. J Med Toxicol. 2015 Mar;11(1):149-52.Full text

Dargan PI, Wallace CI, Jones AL. An evidence based flowchart to guide the management of acute salicylate (aspirin) overdose. Emerg Med J. 2002 May;19(3):206-9.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Diabetic ketoacidosis
- Dementia
- Pneumonia
More Differentials
Guidelines
- Salicylates poisoning
- Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management
More Guidelines
Calculators
Anion Gap
More Calculators
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Salicylate poisoning

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

asymptomatic: without criteria for hospital referral

asymptomatic: with criteria for hospital referral

symptomatic

Contributors

Authors

Chris Hoyte, MD

Disclosures

Eric Lavonas, MD, MS

Disclosures

Acknowledgements

Peer reviewers

Colin A. Graham, MBChB, MPH, MD, FRCSEd, FRCSGlasg, FIMCRCSEd, FCCP, FCEM, FHKCEM, FHKAM

Disclosures

Gerald F. O'Malley, DO

Disclosures

Paul Wax, MD

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Calculators

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice