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Emergency Medicine Blog Tox Pearls

Female holds pills of different color in hand.


April 26, 2019

  • Hidden in many drugs and products: mouthwash, oil of wintergreen, headache/cold medicine, antacids, wart remover
  • Analgesic, anti-inflammatory and antipyretic through inhibition of COX
  • PGe2 → ↑ cAMP → triggers hypothalamus to elevate temp set point → ↑heat generation and ↓heat loss (antipyretic)
  • May directly inhibit neutrophils (anti-inflammatory)
  • uncoupling of oxidative phosphorylation (neuroglycopenia)

Toxic Dose:

150–300 mg/kg mild to moderate toxic reactions, 300–500 mg/kg serious reactions
>500 mg/kg potentially lethal
Ingestion of greater than a lick or taste of oil of wintergreen (98% methyl salicylate) by children <6 y and more than 4 mL by patients > 6 y could cause systemic toxicity

Clinical Picture:

mild to moderate: tinnitus, hearing loss, tachypnea, hyperpyrexia, diaphoresis
Severe: AMS, Sz, ALI, AKI, arrhythmias, Shock

Acute: younger, SI, markedly elevated serum levels, easily recognized hence more readily treated, hence less mortality
Chronic: older, iatrogenic vs therapeutic misadventures, moderate serum level elevation, easily missed, hence higher mortality.
HAGMA, Resp Alk (hypervent), Metabolic alk (if ↑ vomiting), Resp acidosis (ALI)

Serum Concentrations:

Therapeutic: 10-30mg/dL, Toxicity: >40-50mg/dL
Rapidly absorbed forms- measurable levels in 30 minutes
Peak occurs ~6hr after absorption (up to 60hr if EC or ER)
consider obtaining >1 value in any suspected salicylate exposure
Definitely obtain more than one if 1st level is >15 mg/dl
Repeat q3-4h until trending down or undetectable


do not intubate! (try your best not to since any more compromise in respiratory functions may prove deadly, consider HCO3 peri-intubation)

may need high vent requirements (ALI)

Resuscitate using NS then use dextrose containing fluids (neuroglycopenia)

AC (charcoal can be used in acute overdose)
WBI (with EC or ER preparations)

Specific treatment:
HCO3 : 1-2 mEq/kg bolus followed by 150 mEq (3 amps) in 1L D5W until serum pH around 7.5, urine pH 8.0
(Alkalinization: increase pH of both serum and urine to shift towards charged state to prevent neurotoxicity and enhance elimination through the urine.)

Enhanced elimination:
HD indications:
Organ system failure (Renal, CHF, ALI, Hepatic+ coagulopathy)
Severe/persistent (lvl >100mg/dL, Persistent CNS changes, progressive decline in VS, severe acid-base changes despite treatment)

Clinical Bottom Line:

Hidden in many drugs and products, may be clinically challenging to detect in chronic overdose, therefore have a low index of suspicion.
Obtain more than one serum level
Be wary of intubation, hypoglycemia, hypokalemia during alkalinization, and the indications of HD.

Lithium Toxicity

April 19, 2019

Do you have a psychiatric patient with tremors, ataxia, or fasciculations? Think Lithium!

Clinical findings include:
GI symptoms (nausea/vomiting)
EKG changes (including prolonged QTc)

Neurologic changes from subtle symptoms like sluggishness or confusion to seizures and encephalopathy (late signs!) Read more.

The information on these pages is provided for general information only and should not be used for diagnosis or treatment, or as a substitute for consultation with a physician or health care professional. If you have specific questions or concerns about your health, you should consult your health care professional.

The images being used are for illustrative purposes only; any person depicted is a model.

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