Poisonings - salicylates
Red flags
Salicylate poisoning is a dynamic poisoning - the patient who looks stable at 4 h can be dying at 8 h.
- Altered mental state, agitation, confusion, seizure, coma - CNS salicylate penetration; the single most ominous sign
- Falling pH / loss of the compensatory respiratory alkalosis - acidaemia drives non-ionised salicylate into the CNS
- Hyperthermia - uncoupled oxidative phosphorylation; a pre-terminal sign
- Pulmonary oedema (non-cardiogenic) and hypoxia
- Salicylate level >6.5 mmol/L (90 mg/dL) acute, or >5.8 mmol/L (80 mg/dL) with renal impairment
- Rising level on serial measurement - ongoing absorption (enteric-coated, bezoar, pylorospasm)
- Any need for intubation - see Traps: peri-intubation apnoea kills these patients
- Chronic salicylism in an older person - toxic at much lower levels, often misdiagnosed as sepsis or delirium
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