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Aspirin overdose

Definition
Aspirin overdose is the plasma salicylate concentration of 300-500 mg/L in mild toxicity, 500-700 mg/L in moderate toxicity, and > 750 mg/L in severity toxicity.
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Pathophysiology
Aspirin overdose is caused by accidental ingestions in children, suicidal or intentional overdoses in adults.
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Disease course
Acute aspirin overdose results in salicylate poisoning resulting in either mild, moderate, or severe toxicity depending on the plasma salicylate concentration. Mild toxicity presents with burning in the mouth, lethargy, nausea and vomiting, tinnitus, or dizziness. Moderate toxicity includes additional symptoms of tachypnea, hyperpyrexia, sweating, dehydration, loss of coordination, and restlessness. Severe toxicity causes hallucinations, stupor, convulsions, cerebral edema, oliguria, renal failure, cardiovascular failure, metabolic acidosis, and coma.
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Prognosis and risk of recurrence
Severe salicylate poisoning results in 5% mortality.
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Key sources
The following summarized guidelines for the evaluation and management of aspirin overdose are prepared by our editorial team based on guidelines from the Extracorporeal Treatments in Poisoning Workgroup (EXTRIP 2015), the U.S. Department of Health and Human Services (HHS 2007), and the National Poisons Information Service (NPIS 2002).
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Guidelines

1.Classification and risk stratification

Setting of care: refer patients with stated or suspected self-harm or who are the victims of a potentially malicious administration of a salicylate to an emergency department immediately, regardless of the dose reported.
B
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  • Severity grading

2.Diagnostic investigations

Laboratory investigations
Obtain serum salicylate levels, renal function and electrolytes, CBC, and INR in patients with aspirin overdose, including measurements performed at least 4 hours after ingestion.
E
Obtain an arterial blood gas in patients with symptomatic aspirin overdose.
E

3.Medical management

General principles: administer oral or intravenous fluid therapy to patients with mild aspirin overdose.
E
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  • Supportive care

  • Poison center consultation

  • Gastric decontamination

  • Urinary alkalinization

  • Management of metabolic acidosis

4.Inpatient care

Monitoring of urinary alkalinization
Measure urine pH every 1 hour, targeting a urine pH of 7.5-8.5; increase the rate of bicarbonate administration if the urine pH remains < 7.5 (note: avoid serum pH > 7.55, closely monitor serum sodium).
E
Check electrolytes and renal function every 3 hours, and administer supplemental potassium as needed to keep the serum potassium in the range 4.0 to 4.5.
E

5.Therapeutic procedures

Indications for extracorporeal treatment: ECTR is recommended in severe salicylate poisoning.
B
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  • ECTR modality

6.Specific circumstances

Patients with dermal exposure
Perform skin washing with soap and water in asymptomatic patients with dermal exposures to salicylates.
B
Consider discharging asymptomatic patients with dermal exposures to salicylates after skin washing, with observation at home for the development of symptoms.
C

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  • Patients with ocular exposure

7.Follow-up and surveillance

Discharge from hospital: obtain an assessment of the patient's mental state and risk of repeated episodes of deliberate self harm before discharge, ideally performed by a psychiatrist or psychiatric liaison nurse.
E
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