Overdoses Salicylates

1017

Alkaline diuresis is indicated for symptomatic patients with salicylate blood concentrations .40 mg/dL.
Administer 150 mEq (three ampules) sodium bicarbonate in 1,000 mL D W at
5
a rate of 10 to 15 mL/kg/hr if the patient is clinically volume depleted until
urine flow is achieved.
Maintain alkalinization using the same solution at 2 to 3 mL/kg/hr, and monitor
urine output, urine pH (target pH, 7 to 8), and serum potassium. Successful
alkaline diuresis requires the simultaneous administration of potassium chloride.
Give 40 mEq potassium chloride intravenous piggyback (IVPB) over 4 to 5
hours. Give additional potassium chloride either orally or intravenously as needed
to maintain serum potassium concentration above 4 mEq/L.
Use caution with alkaline diuresis in older patients, who may have cardiac,
renal, or pulmonary comorbidity, as pulmonary edema is more likely to occur
in this population.
Do not use acetazolamide (carbonic anhydrase inhibitor). Although acetazolamide
alkalinizes the urine, it increases salicylate toxicity because it also alkalinizes the
CNS (trapping more salicylate in the brain) and worsens acidemia.
Hyperventilate any patient requiring endotracheal intubation. In salicylatepoisoned patients with tachypnea and hyperapnea, the respiratory alkalosis partially
compensates for the metabolic acidosis. Mechanical ventilation with neuromuscular
paralysis, sedation, and normal ventilator rates will remove the respiratory alkalosis, worsen acidosis, and cause rapid deterioration or death.
Treat altered mental status with IV dextrose, despite normal blood glucose.
Treat cerebral edema with hyperventilation and osmotic diuresis.
Treat seizures with a benzodiazepine (diazepam, 5 to 10 mg IV q15min up to
50 mg) followed by phenobarbital, 15 mg/kg IV. Give dextrose 25 g IV immediately following seizure control.
Other Nonpharmacologic Therapies
Hemodialysis is indicated for blood concentrations .100 mg/dL after acute
intoxication. Hemodialysis rapidly removes salicylate and corrects acidosis. Hemodialysis may be useful with chronic toxicity when salicylate concentrations are as
low as 40 mg/dL in patients with any of the following: persistent acidosis, severe
CNS symptoms, progressive clinical deterioration, pulmonary edema, or renal
failure.
Treatment of pulmonary edema may also require mechanical ventilation with a
high fraction of inspired oxygen concentration and positive end-expiratory pressure
(PEEP) (in addition to high respiratory rate).
SPECIAL CONSIDERATIONS
Patients with minor symptoms (nausea, vomiting, tinnitus), an acute ingestion of
,100 mg/kg, and a first blood concentration of ,50 mg/dL may be treated in
the emergency department. Blood concentrations should be repeated every 2 hours
until they show a decline. These patients often are medically stable for discharge,
and their disposition can be determined based on psychiatric evaluation.
Admit moderately symptomatic patients for at least 24 hours. Repeat serum salicylate concentration, electrolytes, BUN, creatinine, and glucose at least every 6 hours
to confirm declining salicylate concentration, improving bicarbonate concentration,