Lithium toxicity — structured clinical viva

Reject the junior plan. Activated charcoal does not bind lithium. Forced loop-diuretic diuresis is not the primary detox strategy. Waiting for Li greater than 5 before nephrology is unsafe: EXTRIP recommends ECTR for decreased consciousness at any lithium level and for impaired kidney function with Li greater than 4.0; it suggests ECTR for significant confusion and when expected time to Li less than 1.0 exceeds 36 hours. This patient is drowsy with AKI and Li 3.1 — call nephrology/toxicology now.^[1][2]

Pattern. Chronic / acute-on-chronic toxicity precipitated by NSAID (naproxen) and thiazide-like diuretic (indapamide) plus age-related clearance risk. Neuro-dominant phenotype; severity can outrun the numerical band expected from acute naive overdose.^[5][3]

Immediate care. Stop lithium, stop naproxen and indapamide, ABC support, ECG monitoring, serial levels, U&E, isotonic saline for volume repletion, early ECTR decision with HD preferred if indicated, plan for rebound checks.^[1][2]

SILENT. Warn that severe neurotoxicity can leave persistent cerebellar/extrapyramidal deficits after levels normalise — motivates aggressive timely care.^[4]

Aftercare. Fix interaction pathway; monitoring education; nuanced restart weighing anti-suicide benefit after recovery.^[6][3]