Salicylate (Aspirin) Poisoning — 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] Salicylate poisoning?
   Suspected salicylate/aspirin poisoning (mixed acid-base)? (Toxic dose ≥150 mg/kg. Classic mixed acid-base: respiratory alkalosis + high-anion-gap metabolic acidosis. Early tinnitus, nausea/vomiting, hyperventilation, tachycardia; late altered mentation, seizures, hyperthermia, cerebral/pulmonary edema. No specific antidote. Check blood gas, anion gap, electrolytes, glucose, serial salicylate levels.)
   • Confirmed/highly suspected → Alkalinize + avoid intubation + dialysis
   • Low suspicion → Low suspicion · monitor
2. [End] Low suspicion · monitor
   Monitor with serial salicylate levels and blood gases; treat as poisoning the moment symptoms appear or levels rise. A single dose of activated charcoal may be given (alert, early).
3. [End] Alkalinize + avoid intubation + dialysis
   1) Support: fluids to correct volume; correct hypokalemia (urine cannot be alkalinized while hypokalemic); give glucose for altered mentation (even if normoglycemic); cooling; benzodiazepines for seizures. 2) Activated charcoal (alert, early; multi-dose or whole-bowel irrigation for sustained-release/enteric-coated). 3) Sodium bicarbonate for blood/urine alkalinization: load 1–2 mEq/kg then a continuous infusion (e.g. 3 ampoules in 1 L D5W + 30–40 mEq KCl), target urine pH 7.5–8.0 and blood pH ≤7.55; do not use acetazolamide. 4) Avoid intubation where possible (the patient depends on compensatory hyperventilation; sedation/intubation can cause sudden deterioration from respiratory acidosis; if intubation is mandatory, give bicarbonate first and match the high minute ventilation). 5) Hemodialysis (EXTRIP): salicylate >100 mg/dL (acute) or >60 (chronic), altered mentation/seizures/cerebral edema, pulmonary edema needing oxygen, renal failure, refractory or worsening acidosis. Consult a poison center.

Source guidelines & references

• ACMT key points on salicylate poisoning management; EXTRIP workgroup
• Palmer BF, Clegg DJ. Salicylate Toxicity. N Engl J Med 2020

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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