What are the guideline sources, guidelines and references for Aspirin overdose ?
Guideline 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). 1 2 2 2 2 3 4 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. 2 Epidemiology Aspirin overdose is caused by accidental ingestions in children, suicidal or intentional overdoses in adults. 4 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 https://web.pathway.md/diseases/recb81eJQsuACVEB7 1/4 6/23/23, 3:12 AM Aspirin overdose Pathway 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. 2 Prognosis and risk of recurrence Severe salicylate poisoning results in 5% mortality. 2 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 Show 2 more Severity grading: very mild poisoning occurs in patients with a salicylate level < 300 mg/L (adults) or < 200 mg/L (children or elderly). These patients are generally asymptomatic. E Show 3 more 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 Show 2 more Supportive care: In patients with aspirin overdose who display severe end-organ manifestations (coma, convulsions, acute renal failure pulmonary edema): initiate hemodynamic and respiratory support perform arterial blood gas sampling discuss with poison control centre and toxicology consider hemodialysis - see therapeutic procedures section. E Poison center consultation: ensure follow-up communication with the poison centre at periodic intervals for at least 12 hours after ingestion of non-enteric-coated salicylate products, and for at least 24 hours after the ingestion of enteric-coated aspirin. B https://web.pathway.md/diseases/recb81eJQsuACVEB7 2/4 6/23/23, 3:12 AM Aspirin overdose Pathway Gastric decontamination: As per HHS 2007 guidelines: Avoid intentionally inducing emesis in patients with aspirin overdose. D Consider the out-of-hospital administration of activated charcoal for acute ingestions of a toxic dose if it is immediately available, no contraindications are present, the patient is not vomiting, and local guidelines for its out-of-hospital use are observed. However, do not delay transportation in order to administer activated charcoal. C As per NPIS 2002 guidelines: Perform gastric lavage (ensuring the airway is protected) in patients who have taken an aspirin dose > 500 mg/kg, within < 1 hour before presentation, and the dose and time of ingestion is certain. E Administer oral activated charcoal (ensuring the airway is protected) in the following situations: patients who have taken an unknown dose of aspirin patients who have taken a dose of aspirin 125 mg/kg patients who have taken a dose of aspirin of > 500 mg/kg, > 1 hour ago (as an alternative to gastric lavage). E Urinary alkalinization: Administer 1.26% sodium bicarbonate with 20 to 40 mmol potassium (1,000 mL IV over 3 hours) as the initial strategy for urine alkalinization in adults with aspirin overdose. E Administer 1 ml/kg 8.4% sodium bicarbonate in 10 ml/kg sodium chloride solution with 1 mmol/kg potassium (IV, at a rate of 2 ml/kg/h) as the initial strategy for urine alkalinization in children with aspirin overdose. E Management of metabolic acidosis: Administer 8.4% sodium bicarbonate (1 mL/kg IV) in patients with aspirin overdose and serum pH < 7.3, targeting an increase pH to 7.4. E Consider performing hemodialysis in addition to giving sodium bicarbonate in patients with a serum pH < 7.2 - see therapeutic procedures section. E 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 https://web.pathway.md/diseases/recb81eJQsuACVEB7 3/4 6/23/23, 3:12 AM Aspirin overdose Pathway Indications for extracorporeal treatment: ECTR is recommended in severe salicylate poisoning. B Show 11 more Extracorporeal treatment modality: use intermittent hemodialysis as the preferred modality of ECTR in patients with aspirin overdose. B Show 2 more 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 Patients with ocular exposure: Perform ocular irrigation with room-temperature tap water for 15 minutes in patients with an ocular exposure to salicylates. B Obtain an ophthalmological consultation if ocular pain, decreased visual acuity, or persistent ocular irritation is present after irrigation. B 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 Show 2 more References 1. Peter A Chyka, Andrew R Erdman, Gwenn Christianson et al. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol Phila). 2007;45 2 95 131. Open 2. P I Dargan, C I Wallace, A L Jones. An evidence based flowchart to guide the management of acute salicylate (aspirin) overdose. Emerg Med J. 2002 May;19 3 206 9. Open 3. David N Juurlink, Sophie Gosselin, Jan T Kielstein et al. Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup. Ann Emerg Med. 2015 Aug;66 2 165 81. Open 4. Debasish Ghosh, Kenneth M Williams, Garry G Graham et al. Multiple episodes of aspirin overdose in an individual patient: a case report. 2014 Nov 19;8 374.2014 Nov 19;8 374. Open https://web.pathway.md/diseases/recb81eJQsuACVEB7 4/4