From the Guidelines
The next step in managing a 21-year-old woman with tinnitus, tachycardia, and alkalosis after an overdose is to initiate urinary alkalinization with sodium bicarbonate to enhance salicylate excretion, as these symptoms strongly suggest salicylate (aspirin) toxicity. The patient's presentation of tinnitus, tachycardia, and alkalosis is consistent with salicylate toxicity, which requires prompt intervention to prevent further complications 1.
Key Considerations
- Obtain serum salicylate levels immediately and arterial blood gases to assess the severity of metabolic acidosis (despite the respiratory alkalosis that may be clinically apparent) 1.
- Administer intravenous fluids with normal saline at 100-200 mL/hour to correct volume depletion.
- Monitor potassium levels closely during alkalinization as hypokalemia can develop.
- For severe toxicity (levels >100 mg/dL, altered mental status, or refractory acidosis), hemodialysis should be considered 1.
Management Approach
- Urinary alkalinization with sodium bicarbonate (150 mEq in 1 L D5W at 1.5-2 times maintenance rate) should be initiated to enhance salicylate excretion by trapping ionized salicylate in the urine.
- The use of sodium bicarbonate is supported by recent guidelines, which recommend its use in the management of patients with cardiac arrest or life-threatening toxicity due to poisoning 1.
- The dose of sodium bicarbonate can be prepared as a 150 mEq/L solution, infused at 1–3 mL∙kg−1∙h−1, with careful monitoring for hypernatremia, alkalemia, hypokalemia, and hypochloremia.
From the FDA Drug Label
Should alkalosis result, the bicarbonate should be stopped and the patient managed according to the degree of alkalosis present. 0.9% sodium chloride injection intravenous may be given; potassium chloride also may be indicated if there is hypokalemia. The most appropriate next step in management is to stop any bicarbonate administration and manage the patient according to the degree of alkalosis present, considering the administration of 0.9% sodium chloride injection intravenous and potentially potassium chloride if hypokalemia is present 2.
From the Research
Patient Assessment and Management
The patient presents with tinnitus, tachycardia, and alkalosis after an overdose, indicating potential salicylate toxicity. Key considerations in management include:
- Limiting absorption of the toxic substance
- Enhancing elimination
- Providing supportive care
Treatment Options
Based on the provided evidence, treatment options for salicylate toxicity include:
- Activated charcoal to decrease absorption 3, 4, 5, 6
- Bicarbonate infusion to maintain a blood pH of 7.5 and enhance elimination 7, 4
- Aggressive hydration to maintain euvolemia 7
- Replenishment of potassium and magnesium 7
- Hemodialysis in severe cases 7
Specific Considerations
- The effectiveness of activated charcoal decreases when administered more than 1 hour after ingestion 3
- Bicarbonate administration can enhance elimination and decrease the apparent elimination half-life 4
- Close monitoring of acid-base status and serum salicylate levels is crucial to detect potential rebound toxicity 7
- Delayed salicylate toxicity can occur, and patients should be monitored for an extended period after ingestion 6