Salicylate poisoning

Last updated: November 20, 2023

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Summarytoggle arrow icon

Salicylate poisoning is a serious complication of aspirin overdose and is characterized by mixed respiratory alkalosis and increased anion gap metabolic acidosis. Early symptoms include tinnitus, nausea, vomiting, and tachypnea. Late symptoms include altered mental status, seizures, and hyperthermia. Fluid resuscitation, oral activated charcoal, and alkalinization of the serum and urine are the most important aspects of treatment. In severe cases, hemodialysis may be indicated. Intubation should be avoided, as it can precipitate clinical decompensation if ventilation needs are not met. For other side effects related to aspirin use, see antiplatelet agents.

Pathophysiologytoggle arrow icon


Pharmacokinetics of poisoning

Clinical featurestoggle arrow icon

Severity of salicylate poisoning [3]
Serum salicylate level Clinical features
Mild poisoning
  • Adults: 30–60 mg/dL
  • Children/older adults: 20–45 mg/dL
Moderate poisoning
  • Adults: 60–80 mg/dL
  • Children/older adults: 45–70 mg/dL
Severe poisoning
  • Adults: > 80 mg/dL
  • Children/older adults: > 70 mg/dL

Diagnosticstoggle arrow icon

Because salicylate levels may be falsely low within 4 hours of ingestion and do not necessarily correlate with clinical presentation, a high index of suspicion should be maintained when caring for a patient with symptoms of salicylate poisoning. Rapid treatment is essential.

Treatmenttoggle arrow icon

General principles [2][3]

Initial assessment and airway management

Indications for intubation in salicylate poisoning

Indications for hemodialysis in salicylate poisoning [4]

Intubating patients with salicylate poisoning is dangerous! If intubation is required, extra care should be taken to maximize minute ventilation, as there is a high risk of worsening acidosis and death.

Salicylate combinations with other substances (like opioids) can lead to mixed intoxications that require specific management (e.g., naloxone).

Gastric decontamination [3][5]

  • Considerations for gastric lavage
    • The ingested aspirin dose is known to be > 500 mg/kg.
    • Ingestion occurred < 1 hour prior to presentation.
  • Considerations for oral activated charcoal
    • The patient must have a secure airway (i.e., is awake and alert or is intubated with an orogastric tube).
    • Timing of ingestion: There are no specific recommendations. [5]
      • 2–4 hours of known ingestion: Giving at least one dose is most likely beneficial.
      • Within 4–24 hours of known ingestion: may be beneficial in some patients (e.g., ingestion of a large amount, severe poisoning)

Fluid and acid-base management [3]

Monitoring and additional concerns

Acute management checklist for salicylate poisoningtoggle arrow icon

Referencestoggle arrow icon

  1. American College of Medical Toxicology. Guidance Document: Management Priorities in Salicylate Toxicity. J Med Toxicol. 2015; 11 (1): p.149-52.doi: 10.1007/s13181-013-0362-3 . | Open in Read by QxMD
  2. $Contributor Disclosures - Salicylate poisoning. All of the relevant financial relationships listed for the following individuals have been mitigated: Jan Schlebes (medical editor, is a shareholder in Fresenius SE & Co KGaA). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy.
  3. Dargan PI. An evidence based flowchart to guide the management of acute salicylate (aspirin) overdose. Emergency Medicine Journal. 2002; 19 (3): p.206-209.doi: 10.1136/emj.19.3.206 . | Open in Read by QxMD
  4. 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; 66 (2): p.165-181.doi: 10.1016/j.annemergmed.2015.03.031 . | Open in Read by QxMD
  5. Olson KR. Activated Charcoal for Acute Poisoning: One Toxicologist’s Journey. Journal of Medical Toxicology. 2010; 6 (2): p.190-198.doi: 10.1007/s13181-010-0046-1 . | Open in Read by QxMD

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