ICU · toxicology

Acute Salicylate Poisoning — Comprehensive ICU Management

Also known as Salicylate poisoning · Aspirin overdose · Salicylism · Oil of wintergreen · Methyl salicylate · Urinary alkalinisation · Ion trapping · Mixed acid-base disorder

Acute salicylate (aspirin) poisoning — uncoupling of oxidative phosphorylation, inhibition of Krebs-cycle dehydrogenases and increased ketoacid production give the signature MIXED acid-base disorder: respiratory alkalosis (direct medullary stimulation) plus high-anion-gap metabolic acidosis. Clinical: tinnitus, hyperventilation, hyperpyrexia, agitation, seizures, non-cardiogenic pulmonary oedema, coma. Severe poisoning: altered mental status, ARDS requiring oxygen, failure of standard therapy, or high serum concentrations — all EXTRIP indications for extracorporeal treatment. Oil of wintergreen is 98% methyl salicylate: one teaspoon (5 mL) equals about 7000 mg salicylate — roughly 22 adult aspirin tablets — and as little as 4 mL can be fatal in a child (Botma) — in children under 6 a teaspoon or less has caused well-documented deaths (Davis). Management: activated charcoal (salicylate is on the charcoal-appropriate list, and a further dose is appropriate), urinary alkalinisation with IV sodium bicarbonate to a urine pH of 7.5 or more — which works only once plasma potassium is corrected to approximately 4 mmol/L — and intermittent haemodialysis (the preferred modality) for severe cases. Above all protect the compensatory hyperventilation: mechanical ventilation at conventional settings abolishes the respiratory alkalosis and drives salicylate into the brain.

Checked against its sources on 2 Sept 2026