3. Introduction
Intentional salicylate overdose usually occurs predominantly in adolescents
& young adults.
Overdoses in children are usually accidental & in the elderly they occur as
therapeutic misadventures.
The severity of aspirin overdose is often underestimated by ER personnel
because of lack of familiarity.
This is an important problem because delay in treatment of severe
intoxication is associated increased mortality in severe cases.
With good management mortality rates are low but even at best about 5% of
severely toxic patients die, usually from cardiovascular & central nervous
system complications.
4. Therapeutic Uses Of Salicylates
Analgesics
Anti inflammatorys
Antipyretics
Keratolytics
Antiplatelets.
5. Salicylate Product Strengths
Adult Aspirin (300mg, 325 mg)
Baby Aspirin (81 mg)
Bismuth subsalicylate
1 ml is equivalent to 8.77 mg of salicylic acid.
60 ml is equivalent to a therapeutic dose (650 mg) of aspirin.
Methylsalicylate
1 teaspoonful (100% MS) = 21 adult strength aspirin
6. Inherent Toxicity
Aspirin
Toxic dose = 150 mg/kg
Minimal lethal dose = 450 mg/kg
Methylsalicylate
Lethal dose in children = 4 cc of 100% MS
Lethal dose in adults = 6 cc of 100% MS
7. Chronic vs Acute Salicylate
Poisoning
Acute
Chronic
Victim
Young Adult
Elderly
Circumstances
Intentional
Accidental
Time To Diagnosis
Short
Long
Mortality
2%
25%
Morbidity
16%
30%
10. PHARMACOKINETICS
Absorbed rapidly by passive diffusion.
90 % Binds to albumin .
Has a very short half-life (30 min).
Metabolized by the liver. (hepatic conjugation with glycin or glucuronic acid).
Excreted in the urine (PH dependent).
11. Pathophysiology of salicylate toxicity.
Metabolic disturbance.
Respiratory system disturbance.
CNS disturbance.
CVS disturbance.
GIT disturbance.
Hematological disturbance.
Musculoskeletal system disturbance.
12. Metabolic Disturbance
Hyperthermia.
Acid-base disturbances (respiratory alkalosis, metabolic acidosis)
Dehydration
Electrolyte imbalance (hypokalemia, hyponatremia)
Altered glucose levels (elevated, normal, or low; CNS glucose concetrations
may be low despite normal or even high blood glucose concentrations)
21.
Laboratory markers:
Serum salicylate:
- Low serum levels early after acute ingestion do not preclude toxicity .
- Levels should be obtained every 2 hours until a decrease is noted on two
consecutive measurements.
- Acute ingestions of non–enteric-coated aspirin should result in peak serum
levels by 6 hours after ingestion. A delayed increase may be seen in patients
with a salicylate pharmacobezoar, patients who have ingested enteric-coated or
sustained-released products (due to delayed absorption), and patients with
worsening acidosis.
- Acute toxicity, levels ranging from 31 to 100 mg/dL
- Chronic toxicity, toxic levels may be as low as 30 to 40 mg/dL
24. Treatment
Fluid resuscitation :
- Correction of dehydration with 0.9% sodium chloride or lactated Ringer solution,
10 to 20 mL/kg/h over 1 to 2 hours until a good urine flow is established of at least
2 to 3 mL/kg/h
GI decontamination:
- Gastric lavage in the first hr (warmed NS 38C,protect airway)
- Activated charcoal in the first 4 hr, 1-2g/kg (maximum 100g)
- Whole-bowel irrigation (WBI) with polyethylene glycol(enteric coated or
slow release formulas, 2 L/h (20 mL/kg/h until the rectal effluent is clear)
Urinary alkalinization with sodium bicarbonate:
- Moderate to sever toxicity.
- 1 to 2 mEq/kg of sodium bicarbonate IV bolus, then infusion of DW5% with 100 to
150 mEq of sodium bicarbonate and 20 to 40 mEq of potassium chloride in each liter
at a rate of 1.5 to 2.5 mL/kg/h.
- Goal urine output is 2 to 3 mL/kg/h.
25.
Hemodialysis:
- Management of patients with salicylate poisoning and a serum salicylate level
>100 mg/dL after acute ingestion or >40 mg/dL after chronic ingestion, altered mental
status, renal failure, pulmonary edema, progressive clinical deterioration, refractory
acidosis, or failure to respond to more conservative therapy.
26. Prognosis
The prognosis in patients with acute salicylate poisoning is very good: the
mortality rate is 1%, and the morbidity rate is 16%
The prognosis is worse in patients with chronic salicylate poisoning: the
mortality rate is 25%, and the morbidity rate is 30%
28.
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