Salicylate poisoning

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 the 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.

Salicylate poisoning is the result of ingestion of, or (rarely) topical exposure to, chemicals metabolized to salicylate.[1]Palmer BF, Clegg DJ. Salicylate toxicity. N Engl J Med. 2020 Jun 25;382(26):2544-55. http://www.ncbi.nlm.nih.gov/pubmed/32579814?tool=bestpractice.com ​ 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]Palmer BF, Clegg DJ. Salicylate toxicity. N Engl J Med. 2020 Jun 25;382(26):2544-55. http://www.ncbi.nlm.nih.gov/pubmed/32579814?tool=bestpractice.com ​ 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]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. https://www.tandfonline.com/doi/full/10.1080/15563650600907140 http://www.ncbi.nlm.nih.gov/pubmed/17364628?tool=bestpractice.com 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]Palmer BF, Clegg DJ. Salicylate toxicity. N Engl J Med. 2020 Jun 25;382(26):2544-55. http://www.ncbi.nlm.nih.gov/pubmed/32579814?tool=bestpractice.com ​