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tox.salicylate-overdose.core.v1PRODUCTION
tox.salicylate-overdose.core.v1

Salicylate (aspirin) overdose

toxicologyacuteadultpediatricgeriatric
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Acute vs chronic salicylate toxicity [ACMT 2023]; identify dialysis-likely subset early [EXTRIP 2015]

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Acuity classified

Patient inputs (18)

Pediatric methyl-salicylate risk; geriatric chronic toxicity [ACMT 2023]

mg/kg ingestion threshold (150 mild / 300 mod / >500 severe); NaHCO3 dosing [AACT 2020]

Chronic toxicity is more dangerous at lower levels — drives lower HD threshold [EXTRIP 2015; ACMT 2023]

Delayed peak up to 24 h — repeat levels q2-4h until peak [AACT 2020]

Aspirin vs bismuth subsalicylate vs methyl salicylate (oil of wintergreen) [ACMT 2023]

q2-4h until peak + 2 falling levels; rebound after HD [EXTRIP 2015]

pH <7.2 is HD criterion + intubation-avoidance trigger [EXTRIP 2015]

Confirms mixed disorder (Winters formula) [AACT 2020]

Component of acid-base interpretation + alkalinization target [AACT 2020]

Anion gap calculation; volume status [AACT 2020]

Hypokalemia BLOCKS urinary alkalinization — must replete [AACT 2020]

Renal failure is HD criterion; impacts chronic-toxicity threshold [EXTRIP 2015]

CNS glucose depletion despite normal serum glucose; D50 indicated [AACT 2020]

Severity + uncoupled oxidative phosphorylation marker [AACT 2020]

Mandatory co-ingestion screen [ACMT 2023]

AMS / seizure / cerebral edema → HD even at lower levels [EXTRIP 2015]

Target >7.5 during alkalinization [AACT 2020]

Non-cardiogenic pulmonary edema is a HD criterion [EXTRIP 2015]

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningsalicylate_level_over_100_acute (AACT 2023)
    Salicylate level >100 mg/dL in acute ingestion (or >90 mg/dL in chronic) [EXTRIP 2015]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpH_under_7_2_or_refractory_acidosis
    Arterial pH <7.2 OR persistent acidosis despite adequate NaHCO3 [EXTRIP 2015]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningAMS_or_seizure_or_cerebral_edema
    Altered mental status, seizure, or signs of cerebral edema [EXTRIP 2015]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningnoncardiogenic_pulmonary_edema
    Non-cardiogenic pulmonary edema on CXR (ARDS pattern) [EXTRIP 2015]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpediatric_methyl_salicylate
    Pediatric ingestion of methyl salicylate (oil of wintergreen) — even small volumes are lethal [ACMT 2023]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereAKI_or_oliguria
    Acute kidney injury OR cannot achieve urine output despite resuscitation OR pre-existing renal failure [EXTRIP 2015]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecannot_tolerate_NaHCO3_fluid_load
    Cannot deliver adequate NaHCO3 due to volume overload, CHF, or anuria [EXTRIP 2015]
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Salicylate — urinary alkalinization + electrolyte/glucose support + dialysis decision (AACT 2023)
axis: salicylate_alkalinization_and_supportivestep 1 - Step 1 — Volume + glucose + electrolyte repletion (concurrent with everything)
Selected step "Step 1 — Volume + glucose + electrolyte repletion (concurrent with everything)" — Any acute or chronic salicylate ingestion with elevated level or end-organ signs
  • normal_saline_or_LR
    first line
    crystalloid
    20 mL/kg IV bolus, then maintenance • IV • bolus + continuous
    triggers: volume_depletion, tachycardia, orthostasis
    Salicylate causes profound volume depletion via insensible losses, vomiting, osmotic diuresis; volume restoration is foundational (AACT 2023)
    rxcui 7407
  • potassium_chloride
    first line
    electrolyte
    20-40 mEq IV per dose; targets K+ 4.0-4.5 • IV • PRN q1-2h titrated
    triggers: K_under_4, hypokalemia_blocks_alkalinization
    Hypokalemia BLOCKS urinary alkalinization (kidney swaps K for H+ — must replete K first) (AACT 2023)
    rxcui 8591
  • dextrose_50
    first line
    glucose_replacement
    25-50 g IV bolus then D5 or D10 infusion • IV • bolus + continuous
    triggers: AMS_even_with_normal_serum_glucose, agitation_or_seizure
    CNS glucose depletion despite normal serum glucose; D50 indicated for any AMS
    rxcui 4850

ed playbook — drug actions (6)

  1. 1. normal_saline_or_LR (AACT 2023)
    rxcui 7407
    20 mL/kg IV bolus then maintenance (AACT 2023) • IV • bolus + continuous
    trigger: Volume depletion (always present) (AACT 2023)
    Foundational — restore volume before alkalinization [AACT 2020]
  2. 2. potassium_chloride
    rxcui 8591
    20-40 mEq IV per dose • IV • PRN q1-2h to K+ 4.0-4.5
    trigger: K+ <4.0 (AACT 2023)
    Hypokalemia blocks alkalinization [AACT 2020]
  3. 3. dextrose_50
    rxcui 4850
    25-50 g IV • IV • PRN + D5/D10 drip
    trigger: Any AMS/agitation regardless of serum glucose (AACT 2023)
    CNS glucose depletion [AACT 2020]
  4. 4. sodium_bicarbonate_bolus
    rxcui 36676
    1-2 mEq/kg IV • IV • bolus once
    trigger: Confirmed salicylate toxicity + K+ repleted (AACT 2023)
    Initiate alkalinization [AACT 2020]
  5. 5. sodium_bicarbonate_infusion
    rxcui 36676
    150 mEq NaHCO3 in 1 L D5W at 150-250 mL/h • IV • continuous
    trigger: Following bolus (AACT 2023)
    Target urine pH 7.5-8.0; serum pH 7.45-7.55 [AACT 2020]
  6. 6. activated_charcoal
    rxcui 272
    50 g PO/NG (1 g/kg peds) • PO/NG • single (repeat for enteric-coated within 4 h)
    trigger: Within 1-2 h ingestion + airway protected (AACT 2023)
    Reduce GI absorption [AACT/EAPCCT position paper] (AACT 2023)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Acute or chronic salicylate / aspirin ingestion [AACT 2020; EXTRIP 2015]; Detectable salicylate level [EXTRIP 2015]; Mixed metabolic acidosis + respiratory alkalosis [AACT 2020].

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Salicylate (aspirin) overdose** (tox.salicylate-overdose.core.v1).
Phenotype framing: Rule out sepsis, DKA, methanol/EG, iron, isoniazid seizure, lactic acidosis, uremia, ARDS, elderly delirium [ACMT 2023]
Scope: Acute vs chronic salicylate toxicity [ACMT 2023]; identify dialysis-likely subset early [EXTRIP 2015]

No severity triggers fired against current inputs.

Plan

Regimen axis: **Salicylate — urinary alkalinization + electrolyte/glucose support + dialysis decision (AACT 2023)** — step "Step 1 — Volume + glucose + electrolyte repletion (concurrent with everything)".
1. normal_saline_or_LR 20 mL/kg IV bolus, then maintenance IV bolus + continuous (crystalloid, first line) — Salicylate causes profound volume depletion via insensible losses, vomiting, osmotic diuresis; volume restoration is foundational (AACT 2023)
2. potassium_chloride 20-40 mEq IV per dose; targets K+ 4.0-4.5 IV PRN q1-2h titrated (electrolyte, first line) — Hypokalemia BLOCKS urinary alkalinization (kidney swaps K for H+ — must replete K first) (AACT 2023)
3. dextrose_50 25-50 g IV bolus then D5 or D10 infusion IV bolus + continuous (glucose_replacement, first line) — CNS glucose depletion despite normal serum glucose; D50 indicated for any AMS

Setting playbook (ed) — Recognize mixed acid-base, replete K+/glucose, start alkalinization, identify dialysis-needed subset, AVOID intubation if at all possible (AACT 2023)
4. normal_saline_or_LR (AACT 2023) 20 mL/kg IV bolus then maintenance (AACT 2023) IV bolus + continuous — Volume depletion (always present) (AACT 2023) (Foundational — restore volume before alkalinization [AACT 2020])
5. potassium_chloride 20-40 mEq IV per dose IV PRN q1-2h to K+ 4.0-4.5 — K+ <4.0 (AACT 2023) (Hypokalemia blocks alkalinization [AACT 2020])
6. dextrose_50 25-50 g IV IV PRN + D5/D10 drip — Any AMS/agitation regardless of serum glucose (AACT 2023) (CNS glucose depletion [AACT 2020])
7. sodium_bicarbonate_bolus 1-2 mEq/kg IV IV bolus once — Confirmed salicylate toxicity + K+ repleted (AACT 2023) (Initiate alkalinization [AACT 2020])
8. sodium_bicarbonate_infusion 150 mEq NaHCO3 in 1 L D5W at 150-250 mL/h IV continuous — Following bolus (AACT 2023) (Target urine pH 7.5-8.0; serum pH 7.45-7.55 [AACT 2020])
9. activated_charcoal 50 g PO/NG (1 g/kg peds) PO/NG single (repeat for enteric-coated within 4 h) — Within 1-2 h ingestion + airway protected (AACT 2023) (Reduce GI absorption [AACT/EAPCCT position paper] (AACT 2023))

Non-pharmacologic actions:
- Foley catheter for hourly UOP and urine pH (AACT 2023)
- Continuous cardiac monitor + SpO2 (AACT 2023)
- Avoid intubation if at all possible — mechanical ventilation cannot reproduce the patient's minute ventilation; profound acidemia and rapid death have occurred (AACT 2023)
- If intubation unavoidable: pre-treat with NaHCO3 bolus, very high RR, large TV; use ketamine + rocuronium induction (AACT 2023)
- Initiate emergent nephrology consult if any EXTRIP criterion met (AACT 2023)
- Cooling for hyperthermia
- Benzodiazepines for seizure or agitation

AVOID / contraindication checks:
- No_intubation_unless_absolutely_required_must_match_minute_ventilation (AACT 2023)
- K_must_be_4_or_above_before_alkalinization (AACT 2023)
- NaHCO3_volume_overload_risk_in_pulm_edema_use_HD (AACT 2023)
- No_acetazolamide_worsens_acidemia (AACT 2023)

Monitoring

Regimen monitoring:
- salicylate q2-4h until peak then falling x2 (AACT 2023)
- ABG q2h during alkalinization (AACT 2023)
- urine pH q1h target 7.5-8.0 (AACT 2023)
- K q2h during alkalinization (AACT 2023)
- glucose q2-4h (AACT 2023)
- continuous telemetry (AACT 2023)
- mental status q1h (AACT 2023)
- hourly UOP (AACT 2023)
- post HD rebound check 2 4h after (AACT 2023)

Setting (ed) monitoring:
- Salicylate level q2-4h until peak documented + 2 falling levels (AACT 2023)
- ABG / VBG q2h during active alkalinization (AACT 2023)
- K+, glucose q2h (AACT 2023)
- Urine pH q1h (target 7.5-8.0) (AACT 2023)
- Mental status / GCS q1h (AACT 2023)
- Hourly UOP (AACT 2023)
- Continuous telemetry (AACT 2023)

Follow-up plan: Psych safety plan, PCP med reconciliation (chronic ASA dose review) [ACMT 2023], social work, nephrology if AKI
- Close-out criterion: Discharge plan + safety plan documented

Monitoring phase: 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]

Disposition

Current setting: ed — Recognize mixed acid-base, replete K+/glucose, start alkalinization, identify dialysis-needed subset, AVOID intubation if at all possible (AACT 2023)

Disposition criteria:
- Discharge after observation: asymptomatic, level <30 mg/dL falling, ABG normal, no co-ingestants, psych cleared (rare) (AACT 2023)
- Admit ward: level falling on alkalinization, no ICU criteria (AACT 2023)
- Admit ICU + nephrology: any EXTRIP HD criterion, AMS, pulm edema, refractory acidosis (AACT 2023)

Escalation triggers (move to higher acuity):
- Level >100 mg/dL (acute) or >90 (chronic) → ICU + emergent HD (AACT 2023)
- pH <7.2 → ICU + emergent HD (AACT 2023)
- AMS / seizure / cerebral edema → ICU + emergent HD (AACT 2023)
- Non-cardiogenic pulmonary edema → ICU + emergent HD (AACT 2023)
- AKI / refractory acidosis despite NaHCO3 → ICU + emergent HD (AACT 2023)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Salicylate level >100 mg/dL in acute ingestion (or >90 mg/dL in chronic) [EXTRIP 2015]
- [LIFE_THREATENING] Arterial pH <7.2 OR persistent acidosis despite adequate NaHCO3 [EXTRIP 2015]
- [LIFE_THREATENING] Altered mental status, seizure, or signs of cerebral edema [EXTRIP 2015]

Citations

- ACMT management priorities in salicylate toxicity + EXTRIP extracorporeal treatment recommendations + salicylate activated-charcoal/bicarbonate evidence [PMID:25715929](https://pubmed.ncbi.nlm.nih.gov/25715929/)
- Cited evidence (PMID 25986310) [PMID:25986310](https://pubmed.ncbi.nlm.nih.gov/25986310/)
- Cited evidence (PMID 34845647) [PMID:34845647](https://pubmed.ncbi.nlm.nih.gov/34845647/)
- Cited evidence (PMID 8629794) [PMID:8629794](https://pubmed.ncbi.nlm.nih.gov/8629794/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ACMT management priorities in salicylate toxicity + EXTRIP extracorporeal treatment recommendations + salicylate activated-charcoal/bicarbonate evidence — PMID:25715929
  • Cited evidence (PMID 25986310) — PMID:25986310
  • Cited evidence (PMID 34845647) — PMID:34845647
  • Cited evidence (PMID 8629794) — PMID:8629794