EM · Toxicology and environmental emergencies
Lithium poisoning
Also known as Lithium toxicity · Lithium intoxication · Acute lithium overdose · Chronic lithium neurotoxicity · Lithium-induced nephrogenic diabetes insipidus
Lithium poisoning — a narrow-therapeutic-index cation that is not protein-bound, not metabolised, and cleared only by the kidney. Hold three patterns (acute in the lithium-naïve, acute-on-chronic, and chronic accumulation). EXTRIP dialysis is decided on impaired kidney function with [Li+] above 4.0 mEq/L, or decreased consciousness, seizures or life-threatening dysrhythmias at any level — not the circulating chronic-2.5 rule. Charcoal does not bind lithium. Stop lithium, give isotonic saline, and plan serial levels for 12 hours after extracorporeal treatment.
Checked against its sources on 3 Sept 2026
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- The toxidrome approach and the general management of the poisoned patient
- Salicylate poisoning
- Tricyclic antidepressant poisoning (emergency department diagnosis and management)
- Paracetamol poisoning
- Seizures and the first fit
- Coma and GCS assessment
- Acute kidney injury
- Electrolyte emergencies — potassium and sodium
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Red flags
- Decreased consciousness, seizures or life-threatening dysrhythmias are EXTRIP 1D indications for extracorporeal treatment at any lithium concentration — do not wait for a 2.5 or 4.0 number
- Chronic toxicity can be clinically severe at a serum lithium as low as 1.5 mEq/L because brain concentrations run ahead of the serum; acute overdose can look deceptively well at a high early level because brain diffusion is delayed about 24 hours
- Activated charcoal does not bind lithium — do not delay saline and dialysis planning for decontamination that will not work
- Atrial fibrillation, a wide QRS and ST elevation in V1–V2 on lithium can be mistaken for acute coronary syndrome; Diserens' case was Brugada syndrome, not a dismissed phenocopy
- Post-dialysis redistribution rebound peaks at 6–12 hours (about 0.5–1.0 mEq/L) and is not typically accompanied by recurrent symptoms; EXTRIP asks for serial levels over 12 hours after interrupting extracorporeal treatment, not a single six-hour re-dialysis trigger
Meet the patient
A 68-year-old woman on long-term lithium for bipolar disorder is brought in after three days of progressive confusion, slurred speech, an unsteady gait and a coarse tremor. She began ibuprofen for osteoarthritis a week ago and has had diarrhoea for two days. The lithium concentration is 2.9 mEq/L, the creatinine 168 micromol/L (baseline 95), and she is drowsy (GCS 13).[1][7]
The number sits in a “moderate” steady-state band, but that band is only a guide. This is chronic poisoning (maintenance therapy plus a drug interaction and volume depletion). Drowsiness with a falling GCS is a decreased level of consciousness — an EXTRIP 1D indication for extracorporeal treatment irrespective of the lithium concentration. Do not wait for 4.0, and do not invent a 2.5 chronic cut-off as if it were EXTRIP.[1]
References7ShowHide
- [1]Decker BS, Goldfarb DS, Dargan PI, Friesen M, Gosselin S, Hoffman RS, Lavergne V, Nolin TD, Ghannoum M; EXTRIP Workgroup. Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup Clin J Am Soc Nephrol, 2015.PMID 25583292
- [2]Baird-Gunning J, Lea-Henry T, Hoegberg LCG, Gosselin S, Roberts DM. Lithium Poisoning J Intensive Care Med, 2017.PMID 27516079
- [3]Timmer RT, Sands JM. Lithium intoxication J Am Soc Nephrol, 1999.PMID 10073618
- [4]Poulsen SB, Kristensen TB, Brooks HL, Kohan DE, Rieg T, Fenton RA. Role of adenylyl cyclase 6 in the development of lithium-induced nephrogenic diabetes insipidus JCI Insight, 2017.PMID 28405619
- [5]McKnight RF, Adida M, Budge K, Stockton S, Goodwin GM, Geddes JR. Lithium toxicity profile: a systematic review and meta-analysis Lancet, 2012.PMID 22265699
- [6]Diserens L, Porretta AP, Trana C, Meier D. Lithium-induced ECG modifications: navigating from acute coronary syndrome to Brugada syndrome BMJ Case Rep, 2021.PMID 34108154
- [7]Ragheb M. The clinical significance of lithium-nonsteroidal anti-inflammatory drug interactions J Clin Psychopharmacol, 1990.PMID 2258452