Salicylate (ASA) Toxicity

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Acute and Chronic Salicylism. Be sure to review the link provided to an ASA case study, found on the last card in this set.

Adult Aspirin = 5 gr (325 mg)
Baby Aspirin = 1.2g gr (81 mg)
Methylsalicylate --1 tsp (100% MS) = 21 Adult Strength Aspirin

Salicylate Product Strengths

Salicylates are present in aspirin medications, Pepto-Bismol® and in high concentrations of oil of wintergreen (methyl salicylate: 1 teaspoon = 7 g of salicylate).

What products are salicylates found in?

1 gr/lb


150 mg/Kg

Toxic Dose of ASA

3-4 gr/lb


450 mg/Kg

Minimal Lethal dose of ASA

In children = 4cc of a 100% solution

In adults = 6 cc of a 100% solution

Lethal Dose of Methylsalicylate

-- Dose
-- Age
-- Renal Function
-- Dehydration
-- Fever

What factors influence salicylate toxicity?


Hyperventilation (30 minutes)

Metabolic Acidosis (12-24 hrs)




What are the manifestations of salicylate poisoning?

Pulmonary Edema

Renal Damage


Complications of salicylate (ASA) poisoning are:

150 mg/Kg -----> No toxicity Expected

150 - 300 mg/Kg -----> Mild to Moderate toxicity Expected

300 - 500 mg/Kg -----> Life Threatening Toxicity Expected (Severe, possibly fatal)

Assessing Salicylate Poisoning Dose:







Symptoms expected with MILD toxicity:








Symptoms expected with MODERATE toxicity:





Respiratory Arrest

Symptoms expected with SEVERE Toxicity:


Blood Glucose


Coags - PT/INR


Urinary pH

Quantitative ASA lvsl q 2 hrs until peaks and see level consistently falling.

Renal Function tests

Labs for assessing salicylate poisoning:

-- May occur when >100mg/Kg/day ingested for 2 or 3 days

-- Severe CNS symptoms, dehydration, hyperventilation

-- ASA lvl of no prognostic value

CHRONIC salicylate (ASA) ingestion:

Prevent Absorption:
-- Lavage
-- AC and cathartic
-- MDAC for asa lvls that continue to rise or for ingestion of enteric coated asa (risk for bezoars)

Enhancing Elimination:
-- Alkaline Diuresis (bicarb gtt w/ potassium supplementation to prevent hypokalemia)
-- Hemodialysis
-- Hemoperfusion

Supportive Care:
-- Fluid/Electrolyte Management
-- alkalization/diuresis for a urine pH of 7.5-8.0
-- aggressive re-hydration

-- sponge baths, fans, cold water submersion

How to Manage ASA/Salicylate Toxicity:

Salicylate Level > 50 mg% accompanied by symptoms and biochemical abnormalities.

What are the indications for Alkaline Diuresis?

Alkalosis, hypernatremia, fluid overload, decreased ionized CA++ and tetany.

What are the risks with Alkaline Diuresis?


What is the treatment of choice for severe asa poisoning?

A Plasma concentrations greater than 700 mg/L (5.1 mmol/L)

Renal failure

Congestive cardiac failure

Non-cardiogenic pulmonary edema



CNS effects not resolved by correction of acidosis

Persistently high salicylate concentrations unresponsive to urinary alkalinization

Severe metabolic acidosis (pH below 7.2)

What are the indications for hemodialyis in ASA toxicity?

Children and the elderly

Late presentation

Pulmonary edema, central nervous system (CNS) features, hyperpyrexia

Metabolic acidosis

Salicylate concentration above 700 mg/L (5.1 mmol/L)

What are risk factors for death in salicylate poisoning?

> 350 mg/L (2.5 mmol/L).

Salicylate intoxication is usually associated with what level ASA concentration?

exceed 700 mg/L (5.1 mmol/L).

Most adult deaths occur in patients whose asa concentrations ...

those under 10 years or over 70 years

Patients in what age group have an increased risk of salicylate toxicity and may require dialysis at an earlier stage?

delayed absorption and toxicity

The development of bezoars in asa toxicity can result in what?


Case Study for Review

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