Salicylate toxicity
Background
- therapeutic: 15mg/kg, 15-30mg/dL, peak level 2-4 h
- large ingestion- peak levels 18-24h (2/2 bezoar/pylorospasm), enteric or SR peak lev up to 60hr
- 1/2 life longer if toxic: 2-4 hr (therapeutic), up to 20hr (toxic)
- decr protein bind: 90% therap, 75% toxic, increases apparent Vd
Pathophys
1.mixed acid-base: primry resp alkalosis & merab acidosis. if have resp acidosis consider a. pulm edema, b. resp depressing co-ingestant, c. resp fatigue
2. fluid loss, lytes off: emesis, tachypnea, kidneys excrete bicarb/K,nonolig RF vs oligur (SIADH)
3. abnml gluc metabolism
4. non-cards pulm & cerebral edema
5. plt dysfxn, anemia (chronic tox)
6. n/v/gastritis/decr gastric motility
7.tinnitus/hear loss (>20-45mg/dL)
Diagnosis
- ASA level, tyl, etoh, utox, UA, icon, ABG, cbc, chem 7, lfts, coag
- ekg
- level >30mg/dL s/s of tox
or, >35 at any time
Treatment
1. sdac 1-2 gm/kg, in right context
2. WBI- consider if enteric/SR
3. IVFs: NS boluses for uop 1-2cc/k/h
4. lytes: consider 40mEq KCl/L, hypoK will prevent urine alkaliniz
5. urine alkaliniz-fxn of flow & pH, consider bicarb if ASA>35 or suspect serious toxicity. 1-2mEq/kg IV bolus then D5W c 3amps bicarb/L @1.5-2x maintenance adjust for goal urine pH>7.5
6. HD: consider if elderly, chronic, AMS, acidemia, severe comorbid
-renal failure
-CHF(relative)
-NCPE, ARDS
-unstable VS
-acid-base/lyte problem p rx
-failed urine alkaliniz
-hepatic failure c coagulopathy
-acute>100, chronic>60 (relative)
- maintain hypervent if intubated
Dialysis
If-
- severely AMS
- coma
- sz
- refractory acidosis
- pulm edema, chf
- renal failure, anuric
- 6hr lvl > 100- 120 in acute OD
Source
Casillas '05