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Salicylate (ASA) Toxicity

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

OR

150 mg/Kg
Toxic Dose of ASA
3-4 gr/lb

OR

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?
Vomiting

Hyperventilation (30 minutes)

Metabolic Acidosis (12-24 hrs)

Hyperthermia

Convulsions

Death
What are the manifestations of salicylate poisoning?
Pulmonary Edema

Renal Damage

Hemorrhage
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:
Nausea/Vomiting,

Dizziness,

Tinnitus,

Lethargy

OR

Dizziness.
Symptoms expected with MILD toxicity:
N/V

Tinnitus

H/A

Confusion

Hyperventilation

Tacchycardia

Fever
Symptoms expected with MODERATE toxicity:
Delirium

Hallucinations

Convulsions

Coma

Respiratory Arrest
Symptoms expected with SEVERE Toxicity:
ABG's

Blood Glucose

CBC

Coags - PT/INR

Lytes

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

Hyperthermia:
-- 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?
Hemodialysis
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

Coma

Convulsions

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?
http://www.reachair.com/education/PDF/CS_Salicylate_Toxicity.pdf

AND

http://clinicalcases.org/2004/02/salicylate-toxicity-presenting-with.html
Case Study for Review