Salicylate Poisoning

Meet the patient

A 29-year-old woman is brought to the emergency department by ambulance after an intentional overdose of three hundred aspirin tablets. She is agitated, breathing deep and fast, and pressing her palms against her ears for the ringing. Her blood gas shows the classic mixed respiratory alkalosis and high-anion-gap metabolic acidosis. The serum salicylate level is 98.2 mg per dL — about 7.1 mmol per litre — and she is already confused.^[19]

The two questions that decide her next hour are the two that decide every salicylate overdose: is her own hyperventilation keeping her alive? and does she already meet a threshold for extracorporeal treatment? With altered mental status and a level above 90 mg per dL she meets EXTRIP indications on both counts. The moment you sedate or intubate her, you take over that first question — and if you get it wrong, she arrests. Hold those two and everything below slots into place.^[1]

References21ShowHide

1. [1]Juurlink DN, Gosselin S, Kielstein JT, et al. Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup Ann Emerg Med, 2015.PMID 25986310
2. [2]Weigel B, Davis C, Bryant SM Urinary Alkalinization for Salicylate Poisoning Is Infrequently Measured nor Achieved Am J Ther, 2025.PMID 40266330
3. [3]Proudfoot AT, Krenzelok EP, Brent J, et al. Does urine alkalinization increase salicylate elimination? If so, why? Toxicol Rev, 2003.PMID 15181662
4. [4]Palmer BF, Clegg DJ. Salicylate Toxicity N Engl J Med, 2020.PMID 32579814
5. [5]Hoegberg LCG, Shepherd G, Wood DM, et al. Systematic review on the use of activated charcoal for gastrointestinal decontamination following acute oral overdose Clin Toxicol (Phila), 2021.PMID 34424785
6. [6]Mullins ME, Kraut JA. The Role of the Nephrologist in Management of Poisoning and Intoxication: Core Curriculum 2022 Am J Kidney Dis, 2022.PMID 34895948
7. [7]O'Keefe M, Stanton M, Feldman R. Incidence of rebound salicylate toxicity following cessation of urine alkalinization Clin Toxicol (Phila), 2023.PMID 37427892
8. [8]Lam RPK, Chan CK, Tse ML. The trajectory of serum salicylate concentrations after ingestion of medicinal oil containing methyl salicylate Clin Toxicol (Phila), 2024.PMID 39387701
9. [9]Berggren J, Jones C, Katz KD. Severe Salicylate Poisoning Due to Teaberry Flavoring Ingestion: A Case Report J Emerg Med, 2025.PMID 39952819
10. [10]McDonald BA, Conlon M, Ulici A. Tracheal Intubation and Mechanical Ventilation in Adults with Severe Salicylate Poisoning J Emerg Med, 2024.PMID 39030088
11. [11]McCabe DJ, Lu JJ. The association of hemodialysis and survival in intubated salicylate-poisoned patients Am J Emerg Med, 2017.PMID 28438446
12. [12]Fernando SM, Charbonneau V, Rosenberg H. Hypercapnea and Acidemia despite Hyperventilation following Endotracheal Intubation in a Case of Unknown Severe Salicylate Poisoning Case Rep Crit Care, 2017.PMID 28465843
13. [13]Wong A, Mac K, Aneman A. Modern Intermittent Haemodialysis (IHD) is an Effective Method of Removing Salicylate in Chronic Topical Salicylate Toxicity J Med Toxicol, 2016.PMID 26334327
14. [14]Hoegberg LCG, Gosselin S, Buckley NA, et al. Recommendations from the Clinical Toxicology Recommendations Collaborative on the administration of activated charcoal in acute oral overdose Clin Toxicol (Phila), 2026.PMID 41906697
15. [15]Dugandzic RM, Tierney MG, Dickinson GE, et al. Evaluation of the validity of the Done nomogram in the management of acute salicylate intoxication Ann Emerg Med, 1989.PMID 2817562
16. [16]Wortzman DJ, Grunfeld A. Delayed absorption following enteric-coated aspirin overdose Ann Emerg Med, 1987.PMID 3826813
17. [17]American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning J Toxicol Clin Toxicol, 1999.PMID 10584586
18. [18]Proudfoot AT, Krenzelok EP, Vale JA. Position Paper on urine alkalinization J Toxicol Clin Toxicol, 2004.PMID 15083932
19. [19]Peketi SH, Upadrista PK, Cadet B, et al. Salicylate Poisoning and Rebound Toxicity Cureus, 2024.PMID 38746490
20. [20]Mayer AL, Sitar DS, Tenenbein M. Multiple-dose charcoal and whole-bowel irrigation do not increase clearance of absorbed salicylate Arch Intern Med, 1992.PMID 1739372
21. [21]Meredith TJ, Vale JA. Non-narcotic analgesics. Problems of overdosage Drugs, 1986.PMID 3552583