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Aspirin can be deadly in overdose! Healthcare providers are encouraged to attend to aspirin poisoning cases with the same diligence afforded to cases of sepsis or other life-threatening diseases. Aspirin poisoning is best cared for by clinicians with appropriate knowledge and experience in treating critical drug poisoning.

Principles of medical management of aspirin poisoning

• After overdose, aspirin may be absorbed from the gut into the bloodstream over a prolonged period of time. Monitor serial serum drug levels, and carefully consider the potential benefit of activated charcoal administration or whole bowel irrigation.
• Aspirin poisoning often leads to dehydration: administer intravenous fluids as necessary to restore and maintain intravascular volume.
• Aspirin may lead to hypoglycemia and/or low CNS glucose availability: monitor blood glucose concentrations and administer dextrose as warranted.
• Aspirin crosses the blood-­brain barrier in acidic blood. Administer IV sodium bicarbonate to achieve a blood pH between 7.45-­7.5. [Many physicians will use D5W with 150 mEq HCO3/L as an initial crystalloid infusion].
• Aspirin poisoning causes hyperventilation which helps to maintain alkalemia. Beware! Giving sedatives may lead to hypoventilation and worsen aspirin poisoning.
• Paralysis and endotracheal intubation may be a lethal procedure! A rise in P_aCO2 (and a resultant decline in serum pH) from paralysis or hypoventilation may lead to an increase in aspirin entry to the brain, and positive-pressure ventilation may reduce cardiac filling. If mechanical ventilation becomes necessary, it is important that hyperventilation and cerebral perfusion be expertly maintained.
• In addition to alkalinizing the bloodstream, sodium bicarbonate helps to alkalinize the urine and promote aspirin elimination by the kidney. Monitor urine pH carefully and try to achieve urine pH 7-8. Hypokalemia will inhibit the ability to alkalinize urine; potassium supplementation is typically necessary.
• Hemodialysis can remove aspirin from the bloodstream and correct fluid, electrolyte, and pH balance. It can be life-saving!

Indications for dialysis (partial listing)

• Worsening confusion, somnolence, or agitation suggesting CNS toxicity
• Seizures (preferably, 30 minutes before seizures occur)
• Pulmonary edema or heart failure complicating IV bicarbonate therapy
• Inability to adequately correct acid-base or electrolyte abnormalities
• Consider strongly if serum salicylate concentration is > 100 mg/dL (acute ingestion) or > 60 mg/dL (acute-on-chronic or chronic ingestion), or if serum salicylate level is rising dangerously fast

Notes on performing dialysis

• The dialysate can be buffered to a pH between 7.45 and 7.5 to maintain alkalemia.
• The dialysis run-time may be more than 3-4 hours; use serial serum salicylate concentrations to determine when dialysis has been sufficiently effective.

Updated: June 1, 2015