Acute salicylate overdose — acid-base, bicarb, dialysis

(i) Acid-base. Mixed disorder: primary respiratory alkalosis (low PaCO2 from medullary stimulation) and primary high anion gap metabolic acidosis (Krebs disruption, lactate, ketoacids, salicylate anion). Not simple compensation.[3]

(ii) Immediate management. ABCDE; avoid unnecessary intubation. Activated charcoal 50 g if airway protected and timing appropriate. IV crystalloid. Correct K+ toward 4–4.5 mmol/L. Urinary alkalinisation: sodium bicarbonate 1–2 mmol/kg IV bolus, then infusion (~1.5 mmol/kg/h in 5% dextrose with KCl 20–40 mmol/bag) aiming serum pH 7.45–7.55 and urine pH ≥7.5–8.0. Serial salicylate levels, gas, K+. If must intubate: bicarb 1–2 mmol/kg pre-induction + match minute ventilation.[3]

(iii) Dialysis. The level of 750 mg/L is approaching the EXTRIP acute concentration threshold (over 7.2 mmol/L = 100 mg/dL = 1000 mg/L, GRADE 1D; over 6.5 mmol/L / 90 mg/dL the weaker 2D threshold) and the patient has significant clinical toxicity — involve nephrology and ICU early for haemodialysis: EXTRIP mandates extracorporeal treatment at ANY concentration for altered mental status, ARDS on oxygen, or failing standard therapy. Continue alkalinisation while organising extracorporeal treatment.[2]