Tinnitus, tachypnea, mixed respiratory alkalosis + anion-gap acidosis
ABCDE Preserve spontaneous ventilation; fluids; alkalinise urine; dialysis if severe.
Calculators: ag osm
Order: Salicylate level; give activated charcoal
Treat: Sodium bicarbonate → alkalinize urine (traps salicylate); replace K
Severe / ↑level / ΔMS → Hemodialysis
Order set Salicylate + paracetamol levels VBG (mixed disorder) U&E, glucose Urine alkalinisation Charcoal Criteria Admit Symptomatic / significant level
ICU Altered mental state, severe acidosis, high level
Dialysis Severe toxicity / very high level / renal failure
Discharge Level falling, acid-base normalised, asymptomatic, psych review
Clinical detail — differentials, red flags, pitfalls, disposition Red flags Altered mental state Severe acidosis High/rising level Differentials DKA Sepsis Other toxic alcohols Common mistakes Intubating (loses compensatory hyperventilation) — if unavoidable: pre-oxygenate, avoid apnoea, match pre-intubation minute ventilation, immediate post-intubation blood gas Delaying dialysis in severe cases Single levels — serial salicylate levels q2h (enteric-coated → delayed/erratic peaks; charcoal may be repeated for bezoar/concretion) Disposition & follow-up Alkalinise + K⁺; haemodialysis if severe.
Discharge package Medications —
Follow-up Psychiatry review
Warning symptoms Tinnitus, confusion, vomiting
💊 Treatment detail — doses & preparation Sodium bicarbonate 8.4% alkalising agent
Dose TCA: 1–2 mmol/kg IV bolus then infusion to pH 7.50–7.55. Salicylate: urine alkalinisation pH 7.5–8.5
Preparation Bolus 50–100 mL of 8.4% (1 mmol/mL); infusion 150 mmol in 1 L D5W + 20–40 mmol KCl
Monitor ABG, K⁺ (hypokalaemia blocks alkalinisation), ionised Ca²⁺, volume
Haemodialysis rescue
Dose EXTRIP 2015: dialysis recommended for altered mental status, acute level >1000 mg/L (≈100 mg/dL), chronic >900 mg/L, renal failure, or refractory acidosis/volume overload; suggested at lower levels with symptoms
Preparation Nephrology emergency
Monitor Levels q2h until falling + asymptomatic
📖 EXTRIP / poisons-centre guidance Reviewed July 2026