Updated: 8/5/2020

Salicylate/Aspirin Overdose

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Snapshot
  • A 20-year-old man presents to the emergency room after an intentional overdose of aspirin. He reports ingesting an unknown amount of aspirin about 30 minutes prior to presentation with the intention of committing suicide. However, he changed his mind and asked to be saved. He reports some nausea, vomiting, and ringing in his ears. He is started on intravenous hydration and given activated charcoal.  
Introduction
  • Clinical definition
    • a constellation of symptoms resulting from toxicity or overdose from salicylates, most commonly aspirin
  • Epidemiology
    • demographics
      • patients taking chronic pain medications
  • Etiology
    • intentional overdose
    • accidental overdose
  • Pathogenesis
    • salicylates have multiple effects on the body
      • hyperventilation and early respiratory alkalosis  
        • aspirin directly stimulates the respiratory centers in the brainstem
      • later metabolic acidosis, resulting in mixed metabolic acidosis-respiratory alkalosis
        • aspirin uncouples oxidative phosphorylation, which impairs the Krebs cycle
          • this results in a lactic acidosis
      • tinnitus
        • aspirin is toxic to cranial nerve VIII
      • acute respiratory distress syndrome
        • aspirin is also toxic to the lungs
      • renal insufficiency
        • aspirin is toxic to the renal tubules
      • increased bleeding time
        • aspirin inhibits platelet aggregation
  • Prognosis
    • depends on the severity of toxicity
    • severe cases may be fatal
Presentation
  • Symptoms
    • tinnitus
    • nausea
    • vomiting
    • fever
    • lethargy
    • seizure or coma (in cases of severe poisoning)
  • Physical exam
    • tachypnea
    • tachycardia
    • hyperthermia
Studies
  • Labs
    • arterial blood gas to evaluate for acidosis or alkalosis
    • serum salicylate level
      • to confirm the diagnosis
      • measure every 3 hours as toxicity can be delayed
    • chemistry panel with liver function tests
      • to assess renal and hepatic function
  • Making the diagnosis
    • based on clinical presentation and laboratory studies
      • especially if patients present with tinnitus, anion gap metabolic acidosis, and elevated serum salicylate levels
Differential
  • Acetaminophen overdose
    • distinguishing factors
      • hepatic failure
      • no tinnitus or acid-base derangement
      • the antidote is N-acetylcysteine
Treatment
  • Conservative
    • supportive care
      • indication
        • for all patients
      • modalities
        • intravenous hydration
  • Medical
    • activated charcoal
      • indications
        • for patients with known salicylate ingestion within the past hour
        • to block absorption
    • sodium bicarbonate
      • indications
        • for patients in whom supportive care is not sufficient, or if patients are not good candidates for activated charcoal
        • alkalinize urine to increase excretion of salicylates
        • alkalinize serum to decrease central nervous system toxicity
  • Non-operative
    • dialysis
      • indication
        • for severe cases (salicylate concentration > 100 mg/dL) or if clinical features are severe
Complications
  • Renal failure

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