Date: March 15, 2011 NOTICE TO INTERESTED PARTIES Bob Buster, Riverside County Board of Supervisors- District 1 John Tavaglione, Riverside County Board of Supervisors-District 2 Jeff Stone, Riverside County Board of Supervisors-District 3 John Benoit, Riverside County Board of Supervisors-District 4 Marion Ashley, Riverside County Board of Supervisors-District 5 California Depart
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Doi:10.1016/j.emc.2007.02.012aDivision of Toxicology, Albert Einstein Medical Center, 5501 Old York Road, bThomas Jeﬀerson University Hospital, Philadelphia, PA 19141, USA cChildren’s Hospital of Philadelphia, Philadelphia, PA 19141, USA dPhiladelphia Poison Control Center, Philadelphia, PA 19141, USA The term salicylate refers to any of a group of chemicals that are derived from salicylic acid. The best known is acetylsalicylic acid (aspirin). Acetyl-salicylic acid is metabolized to salicylic acid (salicylate) after ingestion.
The salicylates originally were derived from salicin, the active ingredientin willow bark, which Hippocrates used 2500 years ago for treating painand fever . Salicylates also occur naturally in many plants such as straw-berries, almonds, and tomatoes .
Poisoning by aspirin is common and is under-represented in poison cen- ter data, because it is often not recognized The in-hospital mortalityfor unrecognized chronic aspirin poisoning is reportedly three times higherthan if the diagnosis is made in the emergency department Familiaritywith the clinical presentation during the various stages of acute and chronicaspirin poisoning is important for the practice of emergency medicine. Themost challenging aspect of the clinical evaluation and management of theaspirin-poisoned patient may be recognition of the subtle signs and symp-toms of chronic, nonintentional aspirin overdose ( Salicylate poisoning continues to be an important overdose that fre- quently presents to emergency departments . There were over 21,000 * Department of Emergency Medicine, Albert Einstein Medical Center, 5501 Old York 0733-8627/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.emc.2007.02.012 Box 1. Pitfalls in the emergency department managementof salicylate–poisoned patients Failure to recognize the presence of salicylate toxicityFailure to appreciate the presence of continued absorption of Misinterpreting clinical significance of serum salicylate levels, Reliance on one or two serum levels of salicylate that may not describe a trend of decreasing total body burden of aspirinclearly Misinterpretation of low serum salicylate levels as nontoxic and failure to comprehend the changing acid–base status of thepatient Waiting until serum salicylate levels are determined before Accidentally adding bicarbonate to isotonic saline (creating a hypertonic solution) rather than intravenous dextrose/watersolutions to alkalinize the urine Forgetting to add potassium to the urinary alkalinization infusionFailure to recognize the emergent need for definitive therapy (hemodialysis) on the basis of impending end organ injury().
Inappropriately or prematurely initiating intubation and mechanical ventilation without hyperventilation and withoutsimultaneous hemodialysis Prematurely discharging patients without demonstrating metabolic stability, declining salicylate levels, and the absenceof an aspirin bezoar aspirin and nonaspirin salicylate exposures reported to the United Statespoison centers in 2004, with 43 deaths and 12,968 patients requiring hospitaltreatment Because poison center data are collected passively, that sta-tistic is certainly an underestimate of the true incidence of salicylate poison-ing occur in the United States. One half of the reported exposures (10,786)were categorized as intentional overdoses. The incidence of chronic aspirinpoisoning is not known, but it is misdiagnosed frequently .
In recent years, packaging strategies such as child-resistant packaging and reducing the amount of medication in each package of over-the-counteranalgesics have impacted the incidence of poisoning. It is estimated that theuse of child-resistant packaging for salicylate-containing medications has re-sulted in a 34% reduction in the salicylate-related child mortality rate .
In England, Australia, and Ireland, analgesics are packaged and sold in MANAGEMENT OF THE SALICYLATE-POISONED PATIENT small amounts (ie, 4 g of acetaminophen). This has resulted in a 30%decrease in the number of patients requiring liver transplantation for acet-aminophen-induced hepatic failure and a 22% reduction in suicidal deathsfrom acetaminophen and salicylate . Large aspirin overdoses werereduced by 39% on average in the countries in which the limited packageformulation is required Salicylate is a metabolic poison. Understanding the pathophysiology of its metabolic eﬀects can help to understand the clinical manifestations of toxic-ity. The metabolic derangements induced by salicylate poisoning are multifac-torial, but the principal pathophysiologic mechanism in salicylate poisoningis interference with aerobic metabolism by means of uncoupling of mitochon-drial oxidative phosphorylation This leads to the interruption of a se-ries of enzyme-mediated mitochondrial functions and increased anaerobicmetabolism with cellular conversion of pyruvate to lactate and rapid develop-ment of lactic acidosis The ineﬃciency of anaerobic metabolism re-sults in less energy being used to create ATP and release of the energycreated during the metabolism of glucose in the electron transport chain asheat, so salicylate poisoned patients may become febrile The absenceof fever, however, does not rule out salicylate poisoning.
The acidosis is caused by anaerobic metabolism and the inability to buﬀer hydrogen ions, which is reﬂected by the accumulation of lactate.
The presence of acetasalicylic acid or salicylate molecules probably contrib-utes little to the acidotic state Interference with oxidative phosphorylation by salicylate also will impact glucose homeostasis negatively by causing glycogen depletion, gluconeogen-esis, and catabolism of proteins and free fatty acids, the end result being lowserum glucose levels and central nervous system (CNS) hypoglycemia rela-tive to serum glucose levels The pharmacokinetic proﬁle of aspirin is unique and explains the unique characteristics of clinical poisoning. The ionization constant (pKa) of aspi-rin is 3, which means that at a pH of 3, approximately half of the availablechemical is in the ionized state. In an acidic environment like the stomach,more of the drug will be absorbed compared with tissues at a higher pH The absorption of aspirin from the stomach can be delayed by the presenceof food in the stomach and the formulation of the aspirin, (eg, enteric coat-ing of pills may create concretions and bezoars that limit available surfacearea for absorption) . Aspirin is thought to cause spasm of the pyloricsphincter, increasing gastric transit time and prolonging the time that aspi-rin is in the acidic environment of the stomach, favoring increased absorption . Salicylates also are absorbed readily in the unionized formfrom the small intestine Dermal salicylate formulations typically do not result in tissue penetra- tion much deeper than 3 to 4 mm in animal studies and human vol-unteer experiments . Methyl salicylate has less dermal absorption thaneither camphor or menthol, with lower mean plasma levels and shorterelimination half-life than either compound in people Signiﬁcantamounts of salicylate typically are not absorbed through the skin exceptin select patients, such as children and patients with compromised skinsuch as burn patients or patients who have severe psoriasis In therapeutic doses, the major route of salicylate biotransformation is conjugation with glycine in the liver. A small amount of aspirin is excretedunchanged in the urine In overdose, the liver’s ability to metabolizethe drug is overwhelmed, and unchanged salicylate excretion through thekidney becomes a much more important elimination route.
Salicylate toxicity initially will create a pure respiratory alkalosis because of direct stimulatory eﬀects on the respiratory centers of the cerebral me-dulla. This is characterized in the blood gas by a decrease in the partial pres-sure of dissolved CO2 accompanied by an elevated pH and normal toslightly lower levels of serum HCO3 . There is some controversy as towhether pediatric aspirin poisoned patients demonstrate this phase ofacid–base derangement. Pediatric patients may present later in the courseof the poisoning, or the centrally mediated hyperventilatory phase of aspirinpoisoning may be so subtle in children that it often is missed As the poisoning progresses and more of the aspirin is absorbed into the serum and is incorporated into the mitochondria, uncoupling oxidativephosphorylation, lactic acid accumulates in the serum, and metabolic com-pensatory mechanisms are initiated Hyperventilation becomes a truecompensatory mechanism in addition to the byproduct of central medullarystimulation This phase is characterized metabolically by a continueddecrease in the pCO2, marked decline in measured HCO3 and possibly a de-crease in serum pH, depending on the ability of the patient to maintain therespiratory demands of the developing acidosis and to retain bicarbonate inthe kidney A common error at this stage of the poisoning is to acknowl-edge that the serum pH is close to 7.4 or slightly higher than 7.4, and assumethat the patient is compensating adequately for the acidosis.
As the ability to compensate for the acidosis is overwhelmed, pH drops; lactic acid accumulates, and serum bicarbonate is consumed. Patients who MANAGEMENT OF THE SALICYLATE-POISONED PATIENT reach the stage of aspirin poisoning where pH is less than 7.4 with decreasedpCO2 and low serum bicarbonate are dangerously unstable, likely todecompensate hemodynamically and will begin to demonstrate other symp-toms of end-organ injury The triad of salicylate poisoning consists of hyperventilation, tinnitus, and gastrointestinal (GI) irritation Physicians should remain awarethat patients may hyperventilate with a normal respiratory rate by increas-ing tidal volume (hyperpnea) and should make it a habit to observe respira-tory patterns carefully. Ototoxicity is a well-described phenomenon withsalicylism, and it is thought to be secondary to interference with chloridechannels in the cochlear hair cells that transmit sound waves . Theototoxicity is most noticeable in the range of serum salicylate from 20 to40 mg/dL . Aspirin, especially enteric-coated formulations, areknown to develop concretions and bezoars in the stomach and act as a directGI irritant leading to nausea, vomiting, and abdominal pain .
Patients who present early in the course of salicylate poisoning may have modest symptoms, and the hyperventilation may be mistaken for emotionalexcitation or anxiety. GI irritation may or may not be present, and tinnitusor other symptoms of ototoxicity may be overlooked unless the physicianspeciﬁcally tests for them with direct questioning or confrontational hearingtesting. Vital signs may reﬂect emotional agitation and CNS stimulationwith tachycardia, increased work of breathing (increased minute ventila-tion), and overall autonomic up-regulation. Early in the course of acute poi-soning, fever generally will be absent Clinical symptoms will be variableif the patient ingested more than one drug, or the ingested aspirin formula-tion contained a CNS depressant, which might blunt the expected hyperven-tilation and respiratory alkalosis .
Laboratory values early in the course of aspirin poisoning will be largely normal or will reﬂect the direct stimulatory eﬀect of salicylate on the cere-bral respiratory center. Serum aspirin levels may be elevated modestly (20to 40 mg/dL), and blood gas analysis may demonstrate pure respiratory al-kalosis with elevated pH and low pCO2 with normal or near-normal HCO3The decision to determine serum salicylate concentrations is not diﬃ-cult. Although serum salicylate levels may not be required to screen everyasymptomatic overdose, liberal use of the laboratory to make the diagnosisand follow resuscitative eﬀorts is advisable .
As salicylate enters the mitochondria, dramatic changes in vital signs and clinical stability occur. Serum salicylate levels alone are not adequate to ac-curately assess and follow seriously poisoned patients Serum salicylatelevels do not reﬂect the total body burden of salicylate, and so to evaluatethe rapidly changing acid base status of an aspirin poisoned patient, serialsalicylate levels should be accompanied by serial blood gas analysis .
Patients who present in the late phases of salicylate toxicity often are mis-diagnosed as sepsis myocardial infarction or as agitated or other-wise psychiatrically disturbed The progression to death from salicylate poisoning is particularly tumul- tuous. The toxic eﬀects of the salicylate molecule on mitochondrial functionand subsequent basement membrane leakage overwhelm the compensatorycapacity of the organism. This leads to marked metabolic acidosis with de-velopment of pulmonary and cerebral edema. Myocardial depression andhypotension secondary to the acidosis and volume deﬁcit occur, and CNSdepression with seizures secondary to hypoxia, hypoglycemia, and directCNS toxicity often precedes cardiopulmonary arrest In one study, nearly half (45%) of the patients who died from salicylate poisoning arrived at the emergency department alert and deteriorated whilethere . In another study, 39% of the patients who had severe salicylatepoisoning requiring ICU management arrived alert with minimal symptoms. Mean postmortem salicylate serum levels on 16 patients who presenteddead on arrival after aspirin overdose were 51 mg/dL (range 17 to 101 mg/dL). Postmortem examination of salicylate-poisoned patients demonstratedseveral unique ﬁndings including myocardial necrosis suggestive of toxicmyocarditis , pulmonary congestion, hemorrhagic gastritis with unab-sorbed salicylate and GI ulceration, cerebral edema, and paratonia (extrememuscle rigidity) Emergency department evaluation of the salicylate-poisoned patient The aspirin nomogram, commonly referred to as the Done nomogram, after its creator Done was ﬁrst published in 1960. Data from pedi-atric patients who ingested a one-time dose of aspirin were plotted overtime to create an instrument to predict toxicity. Several important limita-tions exist with regards to the development of the Done nomogram thatlimit its generalizability, including the fact that patients who had polydrugingestion were included in the analysis, making the clinical correlationdiﬃcult to interpret. In addition, the nomogram assumed an elimination MANAGEMENT OF THE SALICYLATE-POISONED PATIENT half-life of 20 hours in all patients and did not allow for the change fromﬁrst-order to zero-order elimination kinetics that occurs when serum levelsexceed the elimination enzyme systems . Although innovative and oftenaccurate for the intended (pediatric) population, the Done nomogram hasbeen demonstrated to have very limited applicability and usefulness formost aspirin-poisoned patients, and its routine use is discouraged Physicians should make liberal use of blood tests in the evaluation of po- tentially aspirin-poisoned patients. Diﬀerent clinical laboratories may reportsalicylate levels in diﬀerent units of measure (mg/dL versus mmol/L). Clini-cians should maintain consistent use of the respective units of measure toavoid confusion. Seriously aspirin-poisoned patients may display symptomsthat allow an astute practitioner to perform comparative serial examinationsand assess developing toxicity. Accurate recognition of worsening signs oftoxicity, however, is an inexact science with uncertain sensitivity and speci-ﬁcity, especially in the event of polypharmaceutical ingestion or pediatricpatients Serum salicylate levels frequently do not reﬂect the se-verity of the poisoning. Depending on the time since ingestion, presenceof food in the stomach, coingestants, and presence of concretions, amongother variables, symptoms may or may not correlate with serum salicylatelevels. Symptomatic patients suspected of aspirin ingestion or salicylate poi-soning should have serial aspirin levels and blood gas analysis performeduntil a clear trend toward decreasing (not plateau or modestly increasing)levels and metabolic stability as described by the blood gas is present.
Radiographic evaluation of the aspirin poisoned patient is rarely helpful, except for seriously ill patients who may have pulmonary edema or patientswho have altered mental status that might require CT scanning of the headto eliminate the possibility of an alternative cause for a changed level of con-sciousness. Large bezoars of ingested enteric-coated aspirin tablets may ormay not be visible on a radiograph, and the absence of opacity on an ab-dominal radiograph is not adequate to rule out the presence of a largeamount of salicylate in the gut Treatment of the salicylate-poisoned patient Depending on the acuity of the poisoning and the presence of end-organ injury and hemodynamic instability, patients may require early, aggressiveresuscitation and treatment. Most patients who have consequential aspirinoverdose will be somewhat volume deﬁcient because of ﬂuid losses causedby increased respiration, fever, and metabolic activity Volume resus-citation with alkalinized intravenous ﬂuids is reasonable and advisable and should be initiated early in the course of the patient’s treatment so that valu-able time is not lost waiting for laboratory conﬁrmation of elevated salicy-late levels Begin by placing a suﬃcient volume of sodium bicarbonate(three ampules NaHCO3 with 44 mEq Naþ/ampule) into a liter of a glu-cose-containing hypotonic solution, such as 5% dextrose and water and in-fusing at 2 to 3 mL/kg per hour to promote brisk urine output. A total of 40mEq of KCl per liter should be added to prevent hypokalemia.
Salicylate-poisoned patients who require advanced airway management are particularly challenging. Salicylate-intoxicated patients who have de-pressed mental status from the salicylate-induced cerebral hypoglycemiaor acidosis or coingestants who require endotracheal intubation andmechanical ventilation pose a clinical no-win situation for emergency physi-cians, because positive pressure ventilation simply cannot maintain therespiratory rate and metabolic demands of seriously salicylate-poisonedpatients. Hemodynamic instability and worsening of acid–base status willalmost deﬁnitely be the consequence Patients who require endotrachealintubation for airway protection and maintenance almost always should behemodialyzed simultaneously to remove salicylate and the accumulated or-ganic acids. Careful attention to maintaining a favorable acid–base statusthrough the judicious manipulation of ventilator settings should occur soas not to allow hypoventilation and the accumulation of CO2.
The unique characteristics of aspirin in the stomach make gastric decon- tamination particularly problematic. Gastric irritation, induction of nausea,and decreased mental alertness all combine to put the salicylate-poisoned pa-tient at substantial risk for vomiting and aspiration from any attempt at GIdecontamination. Clinicians must weigh the very real risk of aspiration ver-sus the possible beneﬁts from any method of gastric decontamination.
Activated charcoal has been demonstrated to be eﬀective in decreasing the area under the curve for absorbed aspirin, and it is the most widelyused method of gastric decontamination for salicylate-poisoned patients. Multidose activated charcoal similarly has been shown to reduce ab-sorption of aspirin and results in decreased serum levels, but this has nottranslated into an improved morbidity or mortality rate Given thatmultiple doses of activated charcoal are quite safe and generally well toler-ated and seem to result in lower total body burden of aspirin, it is reasonableto recommend 25 g of activated charcoal without sorbitol given orally every3 hours while the patient is being monitored with serial aspirin and bloodgas measurements. Before each 25 g dose of activated charcoal, bowelsounds should be checked, and if absent, the activated charcoal shouldnot be withheld.
Whole-bowel irrigation is not recommended in aspirin-poisoned patients, because there are very little data to support its use in salicylate poisoning.
MANAGEMENT OF THE SALICYLATE-POISONED PATIENT What data do exist do not demonstrate an improved outcome Whole-bowel irrigation with balanced electrolyte solutions decreases guttransit time but may increase total surface area available for absorptionand possibly lead to increased serum levels of aspirin. It is universally poorlytolerated and diﬃcult to perform .
Gastric lavage largely has been abandoned in the management of poi- soned patients with the possible exception of overdose with a life-threaten-ing drug and early presentation of the patient in the course of the poisoning. Serious aspirin poisoning is certainly a life threat and given theunique potential of enteric-coated aspirin to form concretions and remainin the stomach due to pylorospasm , it is reasonable to consider gastriclavage with a large-bore endogastric tube (36 French or larger) if substantialsalicylate poisoning is suspected, and there is no likelihood of airway com-promise .
Restoring intravascular volume and alkalinization of the serum and urine is an important ﬁrst-line treatment for acetasalicylic acid toxicity. Bi-carbonate diuresis is the mainstay and ﬁrst-line treatment for aspirin tox-icity, and it should be initiated early in every case of moderate salicylatepoisoning . The (pKa) is a logarithmic function, so a small change inurine pH will have a disproportionately larger eﬀect on salicylate clearance,so theoretically elimination of salicylic acid is increased substantially in al-kaline urine The most practical method of creating an isotonic alka-line solution in the emergency department is to add sodium bicarbonateto 5% dextrose in water. In general, one 50 mL ampule of 40% sodiumbicarbonate should contain 43 mEq of sodium. By putting three ampules(150 mL total volume) of sodium bicarbonate into one liter of D5W, theresulting solution should have 132 mEq of sodium, which is essentially0.9% (normal) saline . A total of 40 mEq of KCl per liter should beadded to prevent hypokalemia. This solution should be infused rapidly ata rate of at least 2 to 3 mL/kg/hour to maintain a brisk urine output of1 to 2 mL/kg/hr. The enhanced excretion of salicylate requires not justraising the pH of the urine, but also increasing the glomerular ﬁltrationrate The development of cerebral or pulmonary edema following salicylate poisoning is an important consideration, but a concern for possibly causingthese complications should not lead to inadequate or ineﬃcient urinaryalkalinization or intravascular volume restoration. Patients who developworsening respiratory function with increased work of breathing and hyp-oxia consistent with pulmonary edema or who develop altered or decreasedmental status consistent with cerebral edema should have their hydrationand urinary alkalinization interrupted and be evaluated immediately fordeﬁnitive treatment (hemodialysis).
Box 2. Indications for hemodialysis in salicylatedpoisonedpatients Severe acidosis or hypotension refractory to optimal supportive care (regardless of absolute serum aspirin concentration) Evidence of end-organ injury (ie, seizures, rhabdomyolysis, Renal failureHigh serum aspirin concentration (>100 mg/dL) despite relatively Consider for patients who require endotracheal intubation unless that indication for mechanical ventilation is respiratorydepression secondary to a coingestant.
Potassium replacement long has been an important aspect of urinary alkalinization despite a paucity of clinical evidence to support the routinepractice Chronic potassium depletion causes increased reabsorptionof bicarbonate in the proximal renal tubules and diﬃculty achieving an al-kaline urine. The eﬀects of acute potassium depletion on urinary excretionof bicarbonate are uncertain It seems reasonable to infuse potassiumand NaHCO3 simultaneously, especially in patients who are already hypo-kalemic. Urinary alkalinization should be delayed while attempts are madeto replace the serum potassium Hemodialysis is the deﬁnitive treatment to prevent and treat salicylate- induced end-organ injury Indications for dialysis are listed in .
Hemodialysis will remove aspirin in the serum and lactate eﬃciently .
Patients may have metabolized their aspirin and have a low measured serumconcentration of salicylate, but they still may beneﬁt from hemodialysis toremove the byproducts of mitochondrial poisoning. Charcoal hemoperfu-sion is not practical in most circumstances , and hemodialysis hasbecome the preferred method of enhanced elimination of excess serumsalicylate.
Aspirin carries both signiﬁcant adverse eﬀects in therapeutic doses and a substantial risk in overdose, for which there is no antidote. Its risk-beneﬁtproﬁle is probably the poorest of all analgesics currently available over thecounter; this is reﬂected in current trends in analgesic use and overdose ﬁg-ures Emergency physicians must have a healthy respect for the erraticand unpredictable absorption and elimination kinetics of aspirin, the devas-tating physiologic eﬀects of aspirin overdose and the subtle manifestations, MANAGEMENT OF THE SALICYLATE-POISONED PATIENT presentation, and increased mortality of chronic aspirin toxicity. Consulta-tion with the regional poison control center is advised to assist with themanagement and follow-up of all poisoned patients.
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