1. ER Assessment

Unstable Patient

• ABCD assessment

Stable Patient

• Proceed to decontamination and investigations

2. Decontamination

• Gastric Lavage up to 6 hours post-ingestion
• Activated charcoal 1 gm/kg, then MDAC 0.5 gm/kg / 4 h for 24 hours

3. Investigations

• Salicylate blood level (4hrs)
• CBC, PT, PTT, INR, ABG, electrolytes, glucose, KFT, LFT
• Chest X-ray if there is hypoxemia
• Repeat salicylate blood level every 4 hours until fall <15

4. Clinical Classification

Moderate & Severe Cases

• Altered mental status, seizures
• Metabolic acidosis or respiratory alkalosis
• Dehydration
• Pulmonary oedema
• OR SBL > 90 mg/dL
• → ICU Admission

Mild Cases

• Tinnitus & vomiting & salicylate > 30
• → In-patient admission

Asymptomatic Cases

• SBL ≤ 15 mg/dL
• Normal pH
• → Repeat salicylate level after 6h if < 15

5. Alkalinization of Urine

Protocol:

• Initial IV bolus of NaHCO₃ 1–2 mEq/kg then
• NaHCO₃ infusions: 100–150 mEq in 1 liter D5% at 150–200 ml/h (or about twice the maintenance requirements in a child)

Goals of Urinary Alkalization:

• Keep urinary pH 7.5–8
• Blood pH not > 7.55

Monitoring during Alkalinization:

• Salicylate level / 4 h
• ABG / 4 h
• Electrolyte / 4 h
• Urinary pH / 4 hrs
• UOP: 3–5 ml/kg/hr
• Correct hypokalaemia by 40 mEq KCL /L to keep K level at 4–4.5 mEq/L
• Correct hypocalcaemia with calcium gluconate IV (5–10 ml in adults)

Contraindications:

• Renal failure
• ALI
• CHF cerebral edema

Continue alkaline diuresis until salicylate level < 30 mg/dL

6. Discharge Criteria

• Patient is asymptomatic
• SBL < 15 mg/dL
• Normal ABG & electrolytes

7. Indications for Hemodialysis

• Acute toxicity with SBL > 90 mg/dL
• CHF, ARDS, renal failure, coma or seizures
• Refractory AB disturbance
• Hepatic compromise with coagulopathy

Note: Combination with alkalinization (if not contraindicated) achieves rapid initial reduction of salicylate level.