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    Salicylate Poisoning: WWW - Anaesthesia.co - in

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    immortalneo
    Salicylate is used as an analgesic agent for the treatment of mild to moderate pain. Aspirin is used as an anti-inflammatory agent for the treatment of soft tissue and joint inflammation and vasculitides such as acute rheumatic fever and Kawasaki disease. The product is an antipyretic drug. Low-dose aspirin helps to prevent thrombosis. Salicylate ingestion continues to be a common cause of poisoning in children and adolescents. The prevalence of aspirin-containing analgesic products makes these agents, found in virtually every household, common sources of unintentional and suicidal ingestion.

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    Salicylate Poisoning: WWW - Anaesthesia.co - in

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    immortalneo
    184 views23 pages
    Salicylate is used as an analgesic agent for the treatment of mild to moderate pain. Aspirin is used as an anti-inflammatory agent for the treatment of soft tissue and joint inflammation and vasculitides such as acute rheumatic fever and Kawasaki disease. The product is an antipyretic drug. Low-dose aspirin helps to prevent thrombosis. Salicylate ingestion continues to be a common cause of poisoning in children and adolescents. The prevalence of aspirin-containing analgesic products makes these agents, found in virtually every household, common sources of unintentional and suicidal ingestion.

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    Salicylate Poisoning

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    Salicylate is used as an analgesic agent for the treatment of mild to moderate pain. Aspirin is used as an anti-inflammatory agent for the treatment of soft tissue and joint inflammation and vasculitides such as acute rheumatic fever and Kawasaki disease. The product is an antipyretic drug. Low-dose aspirin helps to prevent thrombosis. Salicylate ingestion continues to be a common cause of poisoning in children and adolescents. The prevalence of aspirin-containing analgesic products makes these agents, found in virtually every household, common sources of unintentional and suicidal ingestion.

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    184 views23 pages

    Salicylate Poisoning: WWW - Anaesthesia.co - in

    Uploaded by

    immortalneo
    Salicylate is used as an analgesic agent for the treatment of mild to moderate pain. Aspirin is used as an anti-inflammatory agent for the treatment of soft tissue and joint inflammation and vasculitides such as acute rheumatic fever and Kawasaki disease. The product is an antipyretic drug. Low-dose aspirin helps to prevent thrombosis. Salicylate ingestion continues to be a common cause of poisoning in children and adolescents. The prevalence of aspirin-containing analgesic products makes these agents, found in virtually every household, common sources of unintentional and suicidal ingestion.

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    SALICYLATE POISONING

    www.anaesthesia.co.in

    anaesthesia.co.in@gmail.com

    Aspirin Therapeutic dose 325-650mg 4 hrly adults (>50kg) max 390mg/day child max 15mg/kg 4hrly Toxic dose 150mg/kg Minimal lethal dose 450mg/kg Methyl salicylate(Oil of Wintergreen) contains 7gm/tsf lethal dose children 4cc of 100% MS Adults 6cc of 100% MS

    Factors influencing salicylates toxicity Dose age of victim renal function dehydration fever

    Pharmacokinetic parameters
    Therapeutic Over dose

    Peak blood level


    Protein binding Vd Half life

    2 hrs
    90% 0.15-0.22 L/kg 2-4 hrs

    >6 hrs
    70-90% 0.35 L/kg 18-20 hrs

    methylsalicylate
    Free tissue SA increases
    Hydrolysis in GI tract, liver, RBCs

    % of free SA bound to albumin decreases as the [serum] increases: 75% bound @ 40mgdL 50% bound @ 75mg/dL

    2.5% excreted unchanged in urine (pH independent)

    zero order kinetics once saturated

    zero order kinetics once saturated

    First order kinetics

    Metabolism in overdose Overdosehepatic enz saturated drug half life to 18-36 hrs albumin binding at toxic levels more free drugs SA = Weak Acid At physiological pH most SA is ionized not penetrate tissue well Acidosismore unionised (Diffusable) SA greater tissue penetration

    Stimulates Resp centre (medulla) Hyperventilation Uncouples oxidative phosphorylation Inhibit key dehydrogenase enzymes Rate of metabolism 02 consumption ,glucose utilization ,C02 & heat production Interferes with carbohydrate, protein& lipid metabolism Inhibit hepatic synthesis of clotting factors

    Acute Salicylate Poisoning


    Toxicity dose Mild( 150 mg/kg) Mod(150-300mg/kg) Severe(300-500mg/kg) CLINICAL FEATURES CNS Tinnitus,Auditory acuity, Deafness,Vertigo Agitation,Hyperactivity Delerium,Coma,Convulsion Cerebral oedema

    C/F contd
    Acid-Base & Electrolyte disturbances Resp Alkalosis Metabolic Acidosis Anion gap Hyper or Hyponatremia Hypokalemia Coagulation Abnormalities Hypoprothrombinemia Inhibition of Factors V, VII, X Platelet dysfunction

    C/F contd
    G I System N&V Haemorrhagic gastritis G I motility Hepatic Liver enz Altered glucose metabolism

    C/F contd
    Metabolic Hyperthermia Hypoglycemia Hyperglycemia Ketonuria Pulmonary Tachypnea Non Cardiogenic Pulmonary oedema Renal Sodium& water retention Proteinuria

    Phase
    EARLY

    Toxicity
    No objective findings,subjective complaints Tachypnea Resp. alkalosis Tinnitus Nausea Vomiting Irritability

    LATE

    Hyperpnea

    Hyperthermia Met. Acidosis


    Neurologic (convulsion)

    GI & coagulation abnormalities

    Chronic ingestion
    Dose - may occur when >100mg/kg/day ingested for 2 or more days usu in older pts with chr.med illness Clinical abnormalities
    Severe CNS symptoms, dehydration, hyperventilation

    Salicylates levels of no prognostic valve Toxicity at lower blood level

    Chronic vs acute salicylatepoisoning


    Etiology Dehydration Age Circumstances ACUTE Overdose moderate Young adult Intentional CHRONIC Therapeutic misuse severe Elderly Accidental Lung 25%

    Time to diagnosis Short Mortality 2%

    Morbidity

    16%

    30%

    Diagnosis
    History C/F ABG- resp alkalosis + met.acidosis in absence of diabetic or renal failure Fecl3 test - Urine purple Phenistix Urine/Serum brown Quanitative Serum Salicylate level ( 6 hrs post ingestion)

    Lab Findings Met.acidosis & anion gap PT SGOT,SGPT Hct & WBC Hypernatremia Hypo or Hyperglycemia Hypokalemia

    Management
    Preventing absorption gastric lavage with in 2-4 hrs
    multi dose activated charcoal (1gm/kg) cathartic(sorbitol)

    Enhancing elimination
    Forced alkaline diuresis Hemodialysis Hemoperfusion

    Forced alkaline diuresis


    Indications
    Salicylates level >50mg% accompanied by symptoms & biochemical abnormalities Rehydrate with 0/9% saline @ 10-20ml/hr over 1-2 till urine 3-6ml/kg/hr Diuresis / alkalization with 1 L5% D +88-132mgq/L Sodabicarb + 20-40meq KCl @2-6cc/kg/hr

    Goal urine flow @ 2-3ml/kg/hr Monitoring Acid Base status Na, K, Ca2 Volume status Urine pH 7.5-8

    Forced alkaline diuresis Contd


    Decrease fluid load - elderly ,Pts with renal ds , cardiac ds Utility
    No studies demonstrating a decrease morbidity or mortality with this treatment

    Dangers
    Alkalosis, hypernatremia, fluid overload Decrease ionized Ca++ and tetany

    Hemodialysis
    Indications Absolute
    Renal failure, cardiac failure Hepatic compromise, pulmonary oedema

    Relative
    ASA level >120mg% Unresponsive acidosis Persistent severe CNS manifestations Progressive deterioration despite supportive care

    Exchange transfusions
    49% SA eliminated per exchange complications include sensitization and decrease Ca++

    Hemoperfusion
    Clearance of upto 116ml/min does not correct fluid or electrolyte imbalances

    Supplemental glucose & 02

    Hyperthermia
    Sponge bath, fans, cold water Submersion

    Acidaemia NaHCO3 to correct pH

    pulmonary oedema IPPV + high FiO2 +PEEP Cerebral oedema hyperventilation, mannitol, phenobarbitone Coagulopathy Vit K Seizures Bzd

    Mgmt contd.
    Pts with minor symptoms (N + V, Tinnitus) ingestion <150mg/kg 1st blood < 65mg/dl Can be treated in emergency Repeat blood level 2hrly Admit moderately symptomatic pts atleast 24hr Severe overdose admit in ICU tachypnea, dehydration, pulm oedema, altered mentation, seizures, comma ingestion >300mg/kg Elderly at high risk

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