Thread by @PearloftheWeek

Today's pearl is about Salicylate☠️!

Toxicity is most often seen with acetylsalicylic acid (Aspirin), but also methyl salicylate (Oil of Wintergreen- 5 mL = 22 aspirin), bismuth subsalicylate (Pepto-Bismol), teething gels, & headache preparations (BC Powder) ingestion
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- Mechanism of Action:
Uncouples oxidative phosphorylation & ↑Renal NaHCO3 excretion➡️AG Metabolic Acidosis
Stimulates medullary 🫁 drive ➡️ 1° respiratory alkalosis

- Clinical: Tinnitus, N/V, Tachypnea/Hyperpnea, AMS & Hyperthermia (late)➡️⚠️RAPID DECOMPENSATION
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- Labs: Order at minimum BMP, HFP, VBG, Salicylate /APAP lvl, EOTH, UA,EKG
Salicylate Lvls:
Acute Tox:
15 - 30 mg/dl = therapeutic range
>30 mg/dl = symptoms begin
> 90-100 mg/dl = severe toxicity
Chronic Tox:
40-60 mg/dl = severe toxicity
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- Labs:
Classic EM Board Q: 1° ↑ Anion Gap Metabolic Acidosis (AGMA) + 1° 🫁 Alkalosis
Acute Kidney Injury ➡️ Severe toxicity (renally cleared)
Pay Attn to K+ (want > 4.5 mmol/L), Glucose, Mg (want > 2 mmol/L) levels
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- Management:
1st - Call Tox / Poison Center!!
2nd - Volume resuscitation (1-2 L LR / Plasmalyte, avoid NS (Acidosis)
3rd - GI Decon < 2 hours post ingestion (Charcoal if AAO x3 / OG/NG if intubated) - ⚠️high risk of emesis
4th - Correct K+ (>4.5)/Mg+ (>2)/Hypoglycemia
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5th - Urinary / Serum Alkalinization with NaHCO3: ⬆️ Urinary / Serum pH ➡️↓Neurotoxicity / ↑ Renal excretion
Goal serum pH 7.55 / urine pH 8.0
2 amps NaHCO3 (100 meq) IV push ➡️ 3 amps NaHCO3 (150 meq) in 1 L D5W @ 2x MIVF rate
⚠️Watch for 🫁 edema!
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6th - Hemodialysis: early Nephrology consult!
Indications: Acute salicylate >80 mg/dl, Chronic >60 mg/dl, , severe refractory AGMA, ANY salicylate level with end organ damage (renal failure, hepatic, hypotension, AMS, seizures, 🫁edema / intubation)
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7th - Intubation: LAST RESORT⚠️HIGH RISK
⬆️ Peri-intubation CNS damage / CARDIAC ARREST
Indications: respiratory failure (Winter's), AMS, 🫁 edema (can try BIPAP)
If you have NO CHOICE ➡️ minimize apnea time (ketamine, awake intubation, true RSI), 2 amps NaHCO3 IV push
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7th #2 - Intubation: Vent Settings
Maintain ⬆️ minute ventilation / AGMA compensation: ⬆️ RR & TV
Winter's Formula (identify respiratory failure / needed CO2 for compensation) = PaCO2 = 1.5 x [HCO3-] + 8 +/- 2
⚠️Incorrect vent settings can KILL patients!
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- Disposition: Trend salicylate levels until < 30 mg/dl, prolonged observation (4-6 hours), low threshold for ICU admission, consider congestion and remember to assess for self harm, poison center recommendations
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- Summary:
Consider salicylate toxicity (N/V, Tinnitus, Tachypnea, Psych, Elderly)
1° AGMA + 🫁Alkalosis
Treat aggressively (IVF, Urinary / Serum Alkalinization, K/Mg/Glucose, intubation, hemodialysis), EARLY poison center / Tox / nephrology
⚠️RAPID DECOMPENSATION⚠️
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Salicylate Toxicity #EmergencyMedicine #physicians #residents #nurses #RTs #pharmacists #EMS #paramedic #MedTwitter #Medstudent #FOAMed #MedEd #Students