QuestionSBA
QuestionChoice
This is only indicated in patients with plasma salicylate concentration >700mg/L, severe acidosis, acute kidney injury, congestive cardiac failure or pulmonary oedema
31865
c
Emergency haemodialysis
QuestionChoice
This is correct. This patient should be considered for urinary alkalinisation with IV sodium bicarbonate, although local protocols should be consulted
31863
a
IV sodium bicarbonate
QuestionChoice
Gastric lavage should only be considered within 1 hour of a potentially life threatening overdose
31866
d
Gastric lavage
QuestionChoice
Oral bicarbonate is not advisable as raising the pH of the gastrointestinal lumen can lead to remaining salicylate tablets in the gastrointestinal tract to dissolve and increase absorption of salicylates
31864
b
Oral bicarbonate
QuestionChoice
This is the management for opioid overdose
31867
e
Naloxone
Concept
Chapter
# Summary
 
Aspirin overdose (which is the most common type of salicylate poisoning) may occur accidentally or intentionally as a means of self-harm. Symptoms include nausea and vomiting, epigastric pain, tinnitus, lethargy and confusion. Signs include fever, diaphoresis, seizures and coma. Acid-base balance is complex, with respiratory alkalosis occurring secondary to hyperventilation as well as a metabolic acidosis secondary to the aspirin itself. Investigations include salicylate levels, a VBG to look at acid-base status and bloods for electrolyte levels. Management includes activated charcoal for recent ingestion, intravenous fluids with electrolyte replacement, and sodium bicarbonate which acts to enhance urinary excretion of salicylates. Haemodialysis may be required in severe cases where there are complications such as renal failure, severe metabolic acidosis or seizures.
 

# Definition
 
Aspirin overdose occurs when an excessive amount of aspirin is ingested, either accidentally or intentionally. There is a spectrum of clinical manifestations, ranging from mild toxicity to severe and life-threatening complications.

# Signs and symptoms

Symptoms include:

- Nausea and vomiting
- Tinnitus
- Epigastric pain 
- Confusion
- Dizziness

Signs include:

- Hyperventilation
- Tachycardia and a bounding pulse
- Diaphoresis
- Fevers
- Pulmonary oedema
- Seizures
- Coma

# Investigations
 
**Bedside tests:**

- **Venous blood gas** classically shows respiratory alkalosis initially due to hyperventilation, before progressing to a metabolic acidosis
- **Capillary blood glucose** screening for hypo or hyperglycaemia causing altered mental state; aspirin overdose can cause hypoglycaemia
- **ECG** - aspirin overdose can cause QRS widening, AV block or ventricular arrhythmias
- **Urinary pH** may be measured to guide urinary alkalinisation 

**Blood tests:**

- **Salicylate levels** at repeated intervals (e.g. 2 hourly) until levels stop rising (as absorption of aspirin may be slow), helps to assess severity of poisoning and guide need for haemodialysis if very high
- **U&Es** to monitor electrolytes (hypokalaemia may occur) and for renal failure
- **Paracetamol levels** to screen for a mixed overdose
 
# Management
 
- Give activated charcoal if aspirin ingestion occurred less than 1 hour ago
- IV fluid resuscitation if volume-deplete
- Correct hypokalaemia if present before giving bicarbonate
- IV sodium bicarbonate is given to alkalinise the urine which enhances excretion of salicylates (can cause hypokalaemia so need to monitor potassium as well as urinary pH)
- Manage complications e.g. cooling measures for hyperthermia, benzodiazepines for seizures
- Haemodialysis may be required for severe poisoning, for example:
        - Salicylate levels > 700mg/kg
        - Severe metabolic acidosis 
        - Seizures or coma
- Once stabilised, psychological assessment for patients presenting with an intentional overdose

# NICE Guidelines

[NICE CKS - Poisoning or Overdose](https://cks.nice.org.uk/topics/poisoning-or-overdose/)

# References
 
[BNF - Emergency Treatment of Poisoning](https://bnf.nice.org.uk/treatment-summary/poisoning-emergency-treatment.html)
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Emergency management of aspirin overdose
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Emergency Medicine
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Emergency management of aspirin overdose
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Emergency management of aspirin overdose 1
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Emergency management of aspirin overdose
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Quesmed Tutorial: Drug Toxicity and Overdose
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Emergency management of aspirin overdose
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Emergency management of aspirin overdose 2
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Urinary alkalinisation with intravenous sodium bicarbonate is a key treatment for severe salicylate toxicity.
A 21 year old female presents to the emergency department. She claims she has taken an overdose of aspirin 90 minutes ago. She has a GCS of 15 and her blood tests reveal a salicylate concentration of 550 mg/L (normal therapeutic range 15-30 mg/dL).


Which of the following is the best management for this patient?
a