Lithium Toxicity — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Severity
   Severity (neurotoxicity / lithium level / type)? (Narrow therapeutic window (0.6–1.2 mEq/L). Acute / acute-on-chronic / chronic (dehydration, AKI, NSAIDs/thiazides/ACEi cause accumulation; chronic is more dangerous, symptomatic at low levels). Mainly neurotoxic: tremor (most common) → ataxia, hyperreflexia/clonus, altered consciousness, dysarthria, seizures, coma; can cause SILENT (irreversible). Acute can be delayed (enters the brain over 24 h).)
   • Severe (severe neurotoxicity/seizures/Li >4 with renal injury/cannot tolerate fluids) → Severe → hemodialysis
   • Mild–moderate → Mild–moderate · fluids
2. [End] Mild–moderate · fluids
   Stop lithium and precipitating drugs (NSAIDs/thiazides/ACEi); isotonic saline fluids maintaining urine output to enhance excretion (lithium is handled like sodium); whole-bowel irrigation for sustained-release; activated charcoal is ineffective (unless another toxin is co-ingested); avoid diuretics; serial lithium levels (including a 6 h recheck for rebound), electrolytes, renal function, monitor neurological symptoms. Escalate to dialysis if symptoms worsen.
3. [End] Severe → hemodialysis
   Hemodialysis (definitive enhanced removal) indications: severe neurotoxicity (altered consciousness/seizures), Li >4.0 mEq/L with renal impairment (or >5.0), arrhythmia, inability to tolerate fluids (renal failure/CHF/liver disease), expected failure to fall below <1.0 within 36 h. Dialyze until clinical improvement or Li <1.0, and watch for rebound (tissue lithium redistributes, recheck at 6 h, CVVH can reduce rebound). Stop lithium, isotonic saline fluids, ICU, symptomatic care (seizures, airway).

Source guidelines & references

• EXTRIP indications for extracorporeal removal in lithium toxicity; lithium toxicity (StatPearls)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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