Clinical Commander

All dossiers
tox.salicylate-overdose.core.v1

Salicylate (aspirin) overdose

toxicologyacuteadultpediatricgeriatricacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is fully authored (21/21 quality bar). Atoms split files not present — content is monolithic. No _design-brief.md authored for the salicylate-poisoning package. No discrete `workup.salicylate_overdose` adapter in clinical-tools-registry.ts; acid-base interpretation handled by panel.abg + cascade.acid_base. evidence.pmids array currently empty — manifest cites guidelines by label/year; populate via PubMed before PRODUCTION. Calculator gaps: Done nomogram is RETIRED per ACMT 2023 (correct); osmolar gap referenced as SHOULD-ASK is calc.osm_gap which is not in registry — flag as registry gap. Deepened 2026-04-27: regimen ladder (volume/K+/glucose → alkalinization → HD), ED + ICU playbooks, 7 severity triggers (level >100, pH <7.2, AMS/seizure, pulm edema, AKI, NaHCO3-intolerance, peds methyl-salicylate), siblings vs APAP-OD and toxic alcohols. Activated charcoal RxCUI corrected and live-checked against RxNav 2026-05-22 (272); remaining salicylate regimen RxCUIs still need a full validation pass.

Entry points (4)

  • symptom
    Acute or chronic salicylate / aspirin ingestion [AACT 2020; EXTRIP 2015]
    salicylate_ingestion_history
  • lab_abnormality
    Detectable salicylate level [EXTRIP 2015]
    salicylate_level_detectable
  • lab_abnormality
    Mixed metabolic acidosis + respiratory alkalosis [AACT 2020]
    mixed_acid_base_disorder
  • symptom
    Tinnitus + hyperventilation cluster (classic) [ACMT 2023]
    tinnitus_with_hyperventilation

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Pediatric methyl-salicylate risk; geriatric chronic toxicity [ACMT 2023]
  • weight_kgrequired
    demographic • used at CONTEXT
    mg/kg ingestion threshold (150 mild / 300 mod / >500 severe); NaHCO3 dosing [AACT 2020]
  • acute_vs_chronicrequired
    history • used at CONTEXT
    Chronic toxicity is more dangerous at lower levels — drives lower HD threshold [EXTRIP 2015; ACMT 2023]
  • enteric_coatedrequired
    history • used at CONTEXT
    Delayed peak up to 24 h — repeat levels q2-4h until peak [AACT 2020]
  • product_formrequired
    history • used at CONTEXT
    Aspirin vs bismuth subsalicylate vs methyl salicylate (oil of wintergreen) [ACMT 2023]
  • salicylate_level_serialrequired
    lab • used at INITIAL_WORKUP
    q2-4h until peak + 2 falling levels; rebound after HD [EXTRIP 2015]
  • arterial_phrequired
    lab • used at INITIAL_WORKUP
    pH <7.2 is HD criterion + intubation-avoidance trigger [EXTRIP 2015]
  • pco2required
    lab • used at INITIAL_WORKUP
    Confirms mixed disorder (Winters formula) [AACT 2020]
  • bicarbonaterequired
    lab • used at INITIAL_WORKUP
    Component of acid-base interpretation + alkalinization target [AACT 2020]
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    Anion gap calculation; volume status [AACT 2020]
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    Hypokalemia BLOCKS urinary alkalinization — must replete [AACT 2020]
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Renal failure is HD criterion; impacts chronic-toxicity threshold [EXTRIP 2015]
  • glucoserequired
    lab • used at INITIAL_WORKUP
    CNS glucose depletion despite normal serum glucose; D50 indicated [AACT 2020]
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Severity + uncoupled oxidative phosphorylation marker [AACT 2020]
  • urine_phrequired
    lab • used at TREATMENT
    Target >7.5 during alkalinization [AACT 2020]
  • acetaminophen_levelrequired
    lab • used at INITIAL_WORKUP
    Mandatory co-ingestion screen [ACMT 2023]
  • mental_status_gcsrequired
    symptom • used at RED_FLAGS
    AMS / seizure / cerebral edema → HD even at lower levels [EXTRIP 2015]
  • cxr
    imaging • used at INITIAL_WORKUP
    Non-cardiogenic pulmonary edema is a HD criterion [EXTRIP 2015]

12-phase flow (12)

  1. 1FRAME
    Acute vs chronic salicylate toxicity [ACMT 2023]; identify dialysis-likely subset early [EXTRIP 2015]
    inputs: acute_vs_chronic
    advance: Acuity classified
  2. 2ENTRY
    Recognize ingestion history, classic triad, or chronic creep in elderly [ACMT 2023]
    inputs: age
    advance: Trigger present
  3. 3CONTEXT
    Capture product, enteric-coated form, dose, intent, renal/CKD context, fluid losses [AACT 2020]
    inputs: weight_kg, enteric_coated, product_form
    advance: Context complete
  4. 4RED_FLAGS
    AMS, seizure, ARDS/non-cardiogenic pulmonary edema, pH <7.2, level >100 (acute) or >90 (chronic), AKI, hyperthermia, cerebral edema, refractory acidosis [EXTRIP 2015]
    inputs: mental_status_gcs, arterial_ph, salicylate_level_serial, creatinine
    advance: HD criteria evaluated; emergent HD started if any positive
  5. 5INITIAL_WORKUP
    Serial salicylate, ABG, CMP, glucose, lactate, CBC, INR, LFTs, ethanol, UDS, ECG, CXR, hCG, urine pH, APAP co-screen [AACT 2020; EXTRIP 2015]
    inputs: salicylate_level_serial, arterial_ph, pco2, bicarbonate, sodium, potassium, creatinine, glucose, lactate, acetaminophen_level
    actions: panel.abg, panel.renal, panel.cardiac
    advance: Acid-base picture interpreted
  6. 6BRANCHING_WORKUP
    If chronic + AKI → early HD pathway [EXTRIP 2015]; if methyl salicylate pediatric → PICU [ACMT 2023]; if pulmonary edema on CXR → HD pathway [EXTRIP 2015]
    inputs: cxr
    advance: Branch selected
  7. 7DIFFERENTIAL
    Rule out sepsis, DKA, methanol/EG, iron, isoniazid seizure, lactic acidosis, uremia, ARDS, elderly delirium [ACMT 2023]
    advance: Salicylate confirmed as principal contributor
  8. 8RISK_STRATIFICATION
    Apply EXTRIP 2015 HD criteria [Juurlink JAMA IM 2015]; apply Winters; severity bucket (mild/mod/severe) [AACT 2020]; ICU disposition score
    inputs: salicylate_level_serial, arterial_ph, creatinine
    actions: calc.winters, calc.anion_gap, calc.ckd_epi_2021
    advance: EXTRIP criteria + severity scored
  9. 9TREATMENT
    Volume + glucose + K repletion + NaHCO3 bolus then infusion to urine pH >7.5 [AACT 2020]; AVOID intubation if possible [ACMT 2023]; emergent HD per EXTRIP 2015; benzos for seizure; cooling for hyperthermia
    inputs: urine_ph, potassium, bicarbonate
    advance: Alkalinization active and HD decision made
  10. 10DISPOSITION
    ICU for any end-organ sign or level >40 mg/dL [EXTRIP 2015]; nephrology + toxicology consult; psych if intentional
    advance: Disposition assigned
  11. 11MONITORING
    q2-4h salicylate, q2h ABG/pH, q2h K + glucose, hourly urine pH (target >7.5) [AACT 2020], continuous telemetry, mental status q1-2h, hourly UOP, post-HD rebound check [EXTRIP 2015]
    inputs: salicylate_level_serial, arterial_ph, potassium, urine_ph
    actions: panel.abg, panel.renal
    advance: Levels falling, pH normalizing, no end-organ deterioration
  12. 12FOLLOWUP
    Psych safety plan, PCP med reconciliation (chronic ASA dose review) [ACMT 2023], social work, nephrology if AKI
    advance: Discharge plan + safety plan documented