Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

asymptomatic: without criteria for hospital referral

1st line – observation at home + outpatient follow-up

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ACUTE
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asymptomatic: without criteria for hospital referral
1st line – 

observation at home + outpatient follow-up

Physicians are advised to consult their local poison control center and/or medical toxicologist for guidance.

Regardless of signs and symptoms, patients with any of the following should be referred to a healthcare facility for evaluation:[2] 1) suicidal intent, self-harm, or malicious administration by another person suspected; 2) home situation is of some concern, despite absence of the above; 3) <12 hours since exposure (<24 hours if the exposure was to enteric-coated aspirin) and total amount ingested cannot be estimated; 4) maximum acute dose ingested (based on aspirin equivalency) is >150 mg/kg or >6.5 g; 5) patient is exposed to oil of wintergreen (98% methyl salicylate) - more than a lick or a taste for children <6 years old, or >4 mL if the patient is age 6 years or older.

This schema also applies to pregnant women.

Asymptomatic patients, who meet none of the above criteria for inpatient management, may be considered for observation at home for 12 to 24 hours.If symptoms and signs are absent, dermal exposures can also usually be observed at home after thoroughly washing the affected area with soap and water.[2]

asymptomatic: with criteria for hospital referral

1st line – emergency department referral

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ACUTE
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asymptomatic: with criteria for hospital referral
1st line – 

emergency department referral

Physicians are advised to consult their local poison control center and/or medical toxicologist for guidance.

Referral to the hospital emergency department should be considered for any of the following:[2] 1) if suicidal intent, self-harm, or malicious administration by another person is suspected (patient will require psychiatric evaluation); 2) if the home situation is of some concern, despite absence of the above; 3) if <12 hours since exposure (<24 hours if the exposure was to enteric-coated aspirin) and total amount ingested cannot be estimated; 4) if the maximum acute dose ingested (based on aspirin equivalency) is >150 mg/kg or >6.5 g, whichever is less; 5) if patient is exposed to oil of wintergreen (98% methyl salicylate) - more than a lick or a taste for children <6 years old, or >4 mL if the patient is age 6 years or older.

Consider – gastrointestinal tract decontamination

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ACUTE
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asymptomatic: with criteria for hospital referral
Consider – 

gastrointestinal tract decontamination

Treatment recommended for SOME patients in selected patient group

May be considered as adjunctive therapy after arrival in the hospital emergency department, particularly if bezoars or concretions are suspected, enteric-coated aspirin was ingested, or salicylate levels are rising.[1][2][25][26]

Activated charcoal can be given in the field if it is immediately available and does not delay transportation to the emergency department.

Activated charcoal should be strictly avoided if any contraindications are present (e.g., depressed level of consciousness), unless the airway is protected. Guidance from a poison center or medical toxicologist may be required.

Inducing emesis is not indicated for salicylate ingestions.

Primary options

charcoal, activated: children: 1 g/kg orally as a single dose; adults: 50-100 g orally as a single dose

symptomatic

1st line – hospital admission + supportive care

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ACUTE
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symptomatic
|
mild
1st line – 

hospital admission + supportive care

In cases of mild poisoning, malaise, nausea, vomiting, tinnitus, and dizziness are usually seen, but features of moderate toxicity (tachypnea, hyperpyrexia, diaphoresis, volume depletion, loss of coordination, and restlessness) are absent.[18]​ Features of severe toxicity are also absent (e.g, hypotension, metabolic acidosis that persists after rehydration, oliguria, renal insufficiency or failure, and signs of neurologic toxicity, including hallucinations, stupor, seizures, or coma).[1]

The first step in treating any patient with suspected poisoning or overdose presenting to the emergency department is to ensure airway patency and adequate breathing and circulation.

Hydration should be addressed and any electrolyte abnormalities corrected as soon as possible. Patients are frequently volume-depleted at time of presentation. Two intravenous lines should be placed (one in each arm) in order to begin adequate rehydration and to initiate alkalinization if needed.

Tinnitus and deafness do not require any specific treatment. Tinnitus usually resolves when salicylate level falls to <20 mg/dL.

If deliberate self-harm or suicidal intent is a concern, the patient should be referred for psychiatric evaluation once medically cleared.

These patients should be monitored closely, paying particular attention to any changes in clinical picture, urinary output, and fluid status. Salicylate levels in this group should be measured every 2 to 4 hours until concentration peaks, there are two successively declining levels, and the salicylate level falls below 30 mg/dL (can occur up to 24 hours after ingestion, especially if enteric-coated aspirin is the source).[18]

Consider – gastrointestinal tract decontamination

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ACUTE
|
symptomatic
|
mild
Consider – 

gastrointestinal tract decontamination

Treatment recommended for SOME patients in selected patient group

May be considered as adjunctive therapy after arrival in the emergency department, particularly if bezoars or concretions are suspected, enteric-coated aspirin was ingested, or salicylate levels are rising.[2][25][26]

Activated charcoal can be given in the field if it is immediately available and does not delay transportation to the emergency department.

Activated charcoal should be strictly avoided if any contraindications are present (e.g., depressed level of consciousness), unless the airway is protected. Guidance from a poison center or medical toxicologist may be required.

Multiple-dose activated charcoal may be indicated when there is evidence of ongoing salicylate absorption. Patients should be assessed for normal mental status and active bowel sounds prior to each dose. Dosing should be withheld if there is inability to protect airway or if signs of bowel obstruction or ileus are present.

Inducing emesis is not indicated for salicylate ingestions.

Primary options

charcoal, activated: children: 1 g/kg orally as a single dose, or 0.5 g/kg orally every 2 hours if multiple doses are required; adults: 50-100 g orally as a single dose, or 25 g orally every 2 hours if multiple doses are required

1st line – ICU admission + supportive care

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ACUTE
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symptomatic
|
moderate or severe
1st line – 

ICU admission + supportive care

In addition to symptoms of mild poisoning (malaise, nausea, vomiting, tinnitus, and dizziness), patients with moderate toxicity present with tachypnea, hyperpyrexia, diaphoresis, volume depletion, loss of coordination, and restlessness.[18]

Features of severe toxicity include hypotension, metabolic acidosis that persists after rehydration, oliguria, renal insufficiency or failure, and signs of neurologic toxicity, including hallucinations, stupor, seizures, or coma.[18]

Patients who are sick from coingestants also require intensive care unit (ICU) admission for monitoring and management.

Airway patency with adequate breathing and circulation should be established. Hypoventilation or failure to hyperventilate in the presence of metabolic acidosis can be extremely dangerous to a salicylate-poisoned patient, worsening the acidemia. Patients unable to protect their airway because of neurologic sequelae or seizures, or patients in severe hypoxic respiratory failure, need intubation and mechanical ventilation.[13]​ After successful and rapid intubation, it is critical to ensure hyperventilation to compensate for salicylate-induced metabolic acidosis.

As serious central nervous system effects are often more prominent with chronic salicylate poisoning, these patients usually require ICU management.

Volume depletion should be addressed and any electrolyte abnormalities corrected as soon as possible.

Although anticonvulsants are not usually required, seizures can be terminated by giving benzodiazepines. However, because failure to hyperventilate may be life-threatening, patients requiring benzodiazepines for salicylate-induced seizures frequently require intubation, mechanical hyperventilation, and hemodialysis.[13]​

If deliberate self-harm or suicidal intent is a concern, the patient should be referred for psychiatric evaluation once stable.

Plus – serum and urinary alkalinization

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ACUTE
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symptomatic
|
moderate or severe
Plus – 

serum and urinary alkalinization

Treatment recommended for ALL patients in selected patient group

The mainstay of treatment for patients with moderate to severe clinical signs and symptoms is alkaline diuresis induced by giving intravenous sodium bicarbonate.[1][13][24]​​ Urinary alkalinization has been shown to increase the elimination of salicylate from tissues and serum compared with intravenous fluids alone or forced diuresis.​[1]

Alkalinization of both the serum and the urine helps eliminate salicylates by promoting salicylate ionization. Ionized salicylates cannot be reabsorbed into the renal tubules (thus increasing urinary excretion of salicylates) or cross the blood-brain barrier (thus decreasing central nervous system salicylate concentration).[29]

Key to successful alkalinization is aggressive management of hypokalemia with adequate potassium supplementation, which promotes bicarbonate retention within the urine at tubular level.[13]

The goal of treatment is for serum pH to be approximately normal (7.35 to 7.5) and for urine to be slightly alkaline (7.5 to 8).[24]

Careful critical care monitoring of these patients is required.

Primary options

sodium bicarbonate: consult local hospital protocol for guidance on preparation, dosing, and rate of administration

Consider – gastrointestinal tract decontamination

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ACUTE
|
symptomatic
|
moderate or severe
Consider – 

gastrointestinal tract decontamination

Treatment recommended for SOME patients in selected patient group

May be considered as adjunctive therapy after arrival in the emergency department, particularly if bezoars or concretions are suspected (ingestion of large number of tablets), enteric-coated aspirin ingested, or salicylate levels are rising.[2][25][26]​ Should be strictly avoided in unstable patients. Guidance from a poison center or medical toxicologist may be required.

Activated charcoal (single or multiple dose) may be useful in cases involving delayed absorption of salicylates. Multiple-dose activated charcoal may be indicated when there is evidence of ongoing salicylate absorption. Patients should be assessed for normal mental status and active bowel sounds prior to each dose. Dosing should be withheld if there is inability to protect airway or if signs of bowel obstruction or ileus are present.

Inducing emesis is not indicated for salicylate ingestions.

Primary options

charcoal, activated: children: 1 g/kg orally as a single dose, or 0.5 g/kg orally every 2 hours if multiple doses are required; adults: 50-100 g orally as a single dose, or 25 g orally every 2 hours if multiple doses are required

Consider – emergency hemodialysis

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ACUTE
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symptomatic
|
moderate or severe
Consider – 

emergency hemodialysis

Treatment recommended for SOME patients in selected patient group

Recommended for unstable patients with renal insufficiency, acute respiratory failure, severe uncompensated metabolic acidosis refractory to alkalinization, prolonged corrected QT interval, acute respiratory distress syndrome (ARDS), seizures, and/or salicylate levels >90 mg/dL or salicylate level >80mg/dL and rising despite adequate therapy.​[1][13][24]

Urgent consultation with a specialist nephrologist is advised.

More than one episode of dialysis may be necessary if clinical signs and symptoms persist, regardless of salicylate level.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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