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tox.lithium-toxicity.core.v1

Lithium toxicity

toxicologyacutechronicadultgeriatricacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is a PLACEHOLDER pointing at prisma/seed/manifests/tox.toxic-alcohols.core.v1.ts — a lithium-specific manifest has not been authored (tracked in brief Open gaps). No problem-package directory on disk for lithium toxicity; no bespoke service folder — regimen rendered via regimen-builder.service.ts. No pharmacologic antidote for lithium — the regimen axis is a decontamination + enhanced-elimination ladder; all entries are non_pharm and carry NO rxcui (per authoring spec). EXTRIP 2015 (Decker CJASN) is the disposition spine: HD if level >4.0 (any pattern) OR >2.5 with decreased consciousness/seizure/arrhythmia/impaired clearance; continue HD until <1.0 mEq/L AND post-HD rebound checked. Key teaching encoded: acute (GI-predominant, tolerates high levels, late neuro) vs chronic (neurotoxic at low levels — tremor/ataxia/encephalopathy/seizure, SILENT) vs acute-on-chronic; SR delayed/erratic peak → serial q2-4h levels + WBI (charcoal does NOT bind lithium); isotonic saline (no forced diuresis/thiazide); IHD preferred over CRRT; mandatory post-HD rebound recheck 6-12h. PRODUCTION blockers: lithium-specific manifest + atoms, dedicated lithium-level/EXTRIP calculator (not in clinical-tools-registry.ts; calc.qsofa/calc.news2 used as the available risk surface), Bayesian LRs for chronic-vs-acute discrimination, RxNav not applicable (no drug regimen — non_pharm ladder only).

Entry points (4)

  • history
    Reported acute lithium ingestion (intentional/accidental) — known lithium-treated patient or pill bottle (EXTRIP 2015)
    lithium_overdose_history
  • symptom
    Tremor, ataxia, dysarthria, confusion, myoclonus, or seizure in a patient on chronic lithium (EXTRIP 2015)
    neurotoxicity_on_chronic_lithium
  • lab_abnormality
    Serum lithium >1.5 mEq/L (therapeutic 0.6–1.2) on a routine or screening draw (EXTRIP 2015)
    elevated_lithium_level
  • symptom
    Nausea, vomiting, diarrhea early after acute ingestion (acute pattern, neuro late) (Baird-Gunning 2017)
    gi_predominant_acute

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    Elderly clear lithium poorly (reduced GFR), present with chronic neurotoxicity at lower levels, and are SILENT-prone (Baird-Gunning 2017)
  • exposure_patternrequired
    history • used at CONTEXT
    Acute vs chronic vs acute-on-chronic dictates level interpretation and HD threshold (EXTRIP 2015)
  • time_since_ingestion_hoursrequired
    history • used at CONTEXT
    Acute SR ingestion peaks late and erratically — a single early level under-estimates burden (Baird-Gunning 2017)
  • formulation_immediate_vs_sustained_releaserequired
    history • used at CONTEXT
    Sustained-release → delayed peak + whole-bowel irrigation candidacy; charcoal does NOT bind lithium (AACT/EAPCCT)
  • nephrotoxic_or_clearance_reducing_medsrequired
    medication • used at CONTEXT
    NSAIDs, ACEi/ARB, thiazide diuretics, and metronidazole reduce renal lithium clearance and precipitate chronic toxicity (Baird-Gunning 2017)
  • volume_status_and_precipitantsrequired
    history • used at CONTEXT
    Volume depletion, low-sodium diet, vomiting/diarrhea, AKI, and febrile illness are the dominant chronic precipitants
  • serum_lithium_levelrequired
    lab • used at INITIAL_WORKUP
    EXTRIP 2015 HD criterion anchor; must be serial (q2–4h) given redistribution + SR delayed peak
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Impaired renal function / inability to clear is itself an EXTRIP HD criterion at level >2.5 mEq/L
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    Hyponatremia and nephrogenic DI (hypernatremia) both alter lithium handling; low sodium reduces clearance
  • potassium
    lab • used at INITIAL_WORKUP
    Electrolyte derangement with vomiting/diarrhea; arrhythmia substrate
  • tsh
    lab • used at BRANCHING_WORKUP
    Chronic lithium causes hypothyroidism and may contribute to encephalopathy mimicry; baseline before discharge
  • mental_status_gcsrequired
    vital • used at RED_FLAGS
    Decreased consciousness is an EXTRIP HD criterion at level >2.5 mEq/L (decker 2015)
  • ecg
    imaging • used at INITIAL_WORKUP
    Lithium causes T-wave flattening, QT prolongation, sinus node dysfunction/bradyarrhythmia — arrhythmia is an EXTRIP HD criterion

12-phase flow (12)

  1. 1FRAME
    Classify exposure pattern up front: acute (GI-predominant, high levels tolerated, late neuro) vs chronic (neurotoxicity at LOW levels — tremor/ataxia/encephalopathy/seizure, SILENT risk) vs acute-on-chronic (worst — high level + tissue-loaded) (EXTRIP 2015)
    inputs: exposure_pattern
    advance: Acute / chronic / acute-on-chronic pattern assigned
  2. 2ENTRY
    Capture trigger: reported ingestion, neurotoxicity on chronic lithium, or an elevated screening level (EXTRIP 2015)
    inputs: age, time_since_ingestion_hours
    advance: Trigger documented
  3. 3CONTEXT
    Formulation (IR vs SR — delayed peak + WBI), precipitants (volume depletion, low-sodium diet, NSAID/ACEi/ARB/thiazide/metronidazole, AKI, vomiting/diarrhea, febrile illness, advanced age), baseline renal function and thyroid status (Baird-Gunning 2017)
    inputs: formulation_immediate_vs_sustained_release, nephrotoxic_or_clearance_reducing_meds, volume_status_and_precipitants
    advance: Precipitants + formulation + comorbidity documented
  4. 4RED_FLAGS
    Decreased consciousness, seizure, life-threatening arrhythmia, level >4.0 mEq/L, or level >2.5 mEq/L with impaired renal function — each is an EXTRIP 2015 hemodialysis criterion; SILENT (Syndrome of Irreversible Lithium-Effectuated NeuroToxicity) screen
    inputs: mental_status_gcs, serum_lithium_level, creatinine
    actions: workup.delirium, workup.first_seizure
    advance: EXTRIP HD criteria evaluated; nephrology engaged if any positive
  5. 5INITIAL_WORKUP
    Serum lithium NOW + serial q2–4h (SR delayed/erratic peak), CMP (Cr, Na, K, Ca), TSH, ECG, neuro exam; APAP/salicylate co-screen + β-hCG if intentional (EXTRIP 2015; Baird-Gunning 2017)
    inputs: serum_lithium_level, creatinine, sodium, potassium
    actions: workup.delirium, workup.aki, panel.metabolic, panel.renal, panel.tox_screen, panel.cardiac
    advance: Baseline + first serial level resulted; renal function and ECG reviewed
  6. 6BRANCHING_WORKUP
    Serial level trajectory (rising → ongoing SR absorption → WBI + repeat HD planning); nephrogenic DI screen (polyuria, hypernatremia, urine osm) in chronic; thyroid + renal sequelae workup; if AKI on CKD baseline → workup.aki_on_ckd (EXTRIP 2015)
    inputs: serum_lithium_level, tsh
    actions: workup.aki_on_ckd, workup.encephalopathy
    advance: Level trajectory established; nephrogenic DI and chronic sequelae assessed
  7. 7DIFFERENTIAL
    Distinguish lithium neurotoxicity from serotonin syndrome / NMS (clonus + autonomic + recent serotonergic vs lead-pipe rigidity + neuroleptic), from non-dialysable tox, and from primary CNS/metabolic encephalopathy; lithium tremor + ataxia + nephrogenic DI is the signature (Baird-Gunning 2017)
    advance: Lithium toxicity differential refined; mimics excluded
  8. 8RISK_STRATIFICATION
    Apply EXTRIP 2015: HD if level >4.0 mEq/L (any pattern) OR level >2.5 mEq/L WITH decreased consciousness / seizure / life-threatening arrhythmia OR impaired renal function/inability to clear; severity also tracks neuro exam, not level alone (chronic toxic at low level)
    inputs: serum_lithium_level, creatinine, mental_status_gcs
    actions: calc.qsofa, calc.news2
    advance: EXTRIP status documented; HD vs supportive decision made
  9. 9TREATMENT
    STOP lithium + all offending drugs (NSAID/ACEi/ARB/thiazide/metronidazole); aggressive isotonic 0.9% saline to restore euvolemia + renal clearance; whole-bowel irrigation for SR (charcoal does NOT bind lithium); intermittent hemodialysis per EXTRIP (preferred over CRRT for clearance) until level <1.0 mEq/L; mandatory rebound recheck 6–12h post-HD; benzodiazepine-first seizure control + supportive care
    inputs: serum_lithium_level, creatinine, volume_status_and_precipitants
    advance: Lithium + offending drugs stopped, saline running, WBI for SR if indicated, HD pathway active or excluded
  10. 10DISPOSITION
    ICU + nephrology for any HD candidate, level >4.0, decreased consciousness, seizure, or arrhythmia; transfer to dialysis-capable center if needed; ward only for mild asymptomatic acute with falling levels and normal renal function; psych for intentional (Baird-Gunning 2017)
    advance: Disposition assigned
  11. 11MONITORING
    Serial lithium q2–4h until clearly falling, then q6–12h; MANDATORY rebound level 6–12h after HD (intracellular → plasma redistribution); continuous telemetry, q1h neuro exam, strict I/O + UOP, Na trend (nephrogenic DI), repeat HD if rebound level re-crosses threshold (EXTRIP 2015)
    inputs: serum_lithium_level, creatinine, sodium, mental_status_gcs
    actions: panel.metabolic, panel.renal, calc.news2
    advance: Level falling, post-HD rebound checked and below threshold, neuro improving
  12. 12FOLLOWUP
    Psychiatry safety plan + lithium re-initiation decision (consider alternative mood stabilizer if recurrent toxicity); nephrology for nephrogenic DI / chronic interstitial nephropathy; endocrine for hypothyroidism/hyperparathyroidism; SILENT documentation (irreversible cerebellar deficits) + neurology rehab; education on volume/NSAID/sick-day rules (Baird-Gunning 2017)
    advance: Discharge + safety plan + chronic-sequelae follow-up documented