TOXBASE Factsheet

Aspirin
Updated 8/2003*

Synonyms:
Acetylsalicyclic acid

Ingredients:
Aspirin Tablet - 75 mg, 300 mg

Toxicity:
Ingested dose (mg/kg body weight) >120 >250 500 or more Likely toxicity Mild Moderate Severe - possibly fatal

Salicylates - features and management

Updated 8/2003

Common features:
Salicylates cause vomiting, dehydration, tinnitus, vertigo, deafness, sweating, warm extremities with bounding pulses, increased respiratory rate and hyperventilation. Some degree of acid-base disturbance is present in most cases.

Common acid-base changes:

Adults and children over the age of 4 years: A mixed respiratory alkalosis and metabolic acidosis is the rule with normal or high arterial pH (normal or reduced hydrogen ion concentration). Children aged 4 years or less: A dominant metabolic acidosis with low arterial pH (raised hydrogen ion concentration) is
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common. Acidosis may increase salicylate transfer across the blood brain barrier.

Uncommon features:
Haematemesis, hyperpyrexia, hypoglycaemia, hypokalaemia, thrombocytopaenia, increased INR/PTR, intravascular coagulation, renal failure and non-cardiac pulmonary oedema. Central nervous system features including confusion, disorientation, coma and convulsions are less common in adults than in children.

Assessment of the severity of poisoning:

The severity of poisoning cannot be assessed from plasma salicylate concentrations alone and clinical and biochemical features should be taken into account. However, salicylate intoxication is usually associated with plasma concentrations > 350 mg/L (2.5 mmol/L). Most adult deaths occur in patients whose concentrations exceed 700 mg/L (5.1 mmol/L). Neurological features including confusion and impaired consciousness, metabolic acidosis and high salicylate concentrations indicate severe poisoning. Risk factors for death include: * age over 70 years or less than 10 years * CNS features * acidosis * hyperpyrexia * late presentation * pulmonary oedema * salicylate concentrations > 700 mg/L

Management:
NB Salicylate poisoning is potentially fatal. 1. Consider oral activated charcoal (50 g for an adult, 10-15 g for a child) in adults and children who have ingested more than 120 mg/kg body weight salicylate within 1 hour. 2. There is no need to measure salicylate concentrations in conscious overdose patients who deny taking salicylate-containing preparations and who have no features suggesting salicylate
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toxicity. 3. Plasma salicylate concentrations should be measured urgently for patients who are thought to have ingested > 120 mg/kg of aspirin, as well as those who have taken methyl salicylate or salicylamide. The sample should be taken at least 2 hours (symptomatic patients) or 4 hours (asymptomatic patients) following ingestion, since it may take several hours for peak plasma concentrations to occur. A repeat sample should be taken after a further 2 hours in patients with suspected severe toxicity following recent ingestion because of the possibility of continuing absorption. Under these circumstances, measurements should be repeated until concentrations are falling. 4. Carry out arterial blood gas analysis. In children, capillary gases or venous blood gases would be a suitable alternative. 5. Check U & Es, INR/PTR and blood glucose. 6. If the serum potassium concentration is within the normal range correct metabolic acidosis with intravenous sodium bicarbonate. If the serum potassium is low this must be corrected before giving sodium bicarbonate. 7. If the serum potassium concentration is within the normal range give sodium bicarbonate intravenously to enhance the urinary salicylate excretion (optimum urine pH 7.5-8.5) using the following dosage regime: If the salicylate concentration in adults > 500 mg/L (3.6 mmol/L) Dose: 1.5 L of 1.26% sodium bicarbonate over 2 hours (or 225 mL 8.4%) If the salicylate level in children (aged < 5 years) > 350 mg/L (2.5 mmol/L) Dose: 1 mL/kg 8.4% bicarbonate diluted in 0.5L in 5% dextrose or normal saline at 2-3 mL/kg/ hour Further amounts of sodium bicarbonate (8.4%) may be required to maintain the urine pH 7.58.5 The plasma salicylate concentration should be repeated to ensure that treatment has been effective. Effective alkalinisation of the urine may be complicated by hypokalaemia and therefore it is important to recheck the plasma potassium.

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Forced diuresis should not be used since it does not enhance salicylate excretion and may cause pulmonary oedema. 8. Haemodialysis is the treatment of choice for severe poisoning and should be seriously considered in patients with: * plasma concentrations greater than 700 mg/L (5.1 mmol/L) * renal failure * congestive cardiac failure * non-cardiogenic pulmonary oedema * convulsions * CNS effects not resolved by correction of acidosis * persistently high salicylate concentrations unresponsive to urinary alkalinisation * severe metabolic acidosis. Patients < 10 years or > 70 years have increased risk of salicylate toxicity and may require dialysis at an earlier stage. Children who require haemodialysis should be discussed with the local paediatric intensive care unit. 9. Repeat plasma salicylate concentrations will be required to ensure that treatment has been effective. 10. A second dose of charcoal may be warranted in patients whose blood level continues to rise, suggesting delayed gastric emptying, or who have taken enteric coated preparations where absorption may be slower. NB Salicylate poisoning is potentially fatal - please call your local poisons service for serious cases: in the UK NPIS 0870 600 6266; in Ireland NPIC (01) 8379964

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