Recommendations for starting hemodialysis in salicylate toxicity

Screen Shot 2015-06-30 at 5.55.50 PM3.5 out of 5 stars

Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup. Juurlink D et al. Ann Emerg Med 2015 May 8 [Epub ahead of print]


Aspirin is an especially dangerous poison for a number reasons:

  • • It’s easy to purchase over-the-counter in large quantities
  • • Even after a life-threatening acute ingestion of salicylate, a patient can present looking deceptively stable only to deteriorate catastrophically several hours later
  • • In chronic salicylate toxicity, the diagnosis can be easily missed

Ask many toxicologists about the poisons they fear the most, and aspirin will — more often than not — be high on the list.

This paper, from the Extracorporeal Treatments in Poisoning (ExTRIP) workgroup, reviewed the literature on salicylate toxicity to determine evidence- and consensus-based recommendations on indications for use of extracorporeal treatment (essentially hemodialysis) in these cases. The emphasis, as in the group’s papers on other poisons, is on consensus rather than evidence, since the group has consistently found that the level of evidence for use of hemodialysis in any poisoning is very poor, amounting to — their words, not mine — “just a guess.”

All of the recommendations presented here are rated as 1D — “1” representing a “strong recommendation,” “D” indicating that it is based on a “very low level of evidence.” I won’t even get into the group’s confusing distinction between a “recommendation” and a somewhat weaker “suggestion.”

I’ll just summarize the group’s recommendations for starting hemodialysis in salicylate toxicity:

  • Salicylate level > 100 mg/dL
  • Salicylate level > 90 mg/dL in presence of impaired kidney function*
  • Altered mental status
  • New hypoxemia requiring supplemental oxygen

*Criteria for impaired kidney function include any of the following:

  1. estimated glomerular filtration rate < 45 mL/min per 1.73 m3
  2. creatinine > 2 mg/dL in adults or > 1.5 mg/dL in elderly or patients with low muscle mass
  3. oliguria/anuria for > 6 hours [NOTE: strangely, the recommendations say little about the importance of correcting volume status]

As we’ve noted before in reviewing the other ExTRIP papers, these parameters are really consensus opinions rather than evidence-based guidelines, but given the impressive multi-specialty composition of the workgroup, they are well worth considering, and the stated rationales are helpful. Since salicylate is such a dangerous ingestion, I completely agress with the concept of having a rather low bar for initiating hemodialysis, which will not only accelerate removal of salicylate but also help correct acidosis.

Related posts:

Excellent guidelines for managing salicylate overdose

Hemodialysis in metformin poisoning

Hemodialysis in acute methanol poisoning: is there really good evidence?

Hemodialysis in lithium poisoning: what is the evidence?

Must-read: consider hemodialysis in cases of massive acetaminophen overdose

What enhanced elimination techniques are useful in critical toxicology patients

Hemodialysis and other extracorporeal modalities in toxicology cases



Tox Tunes #97: Resurrection Mary (Ian Hunter)

Combining Chicago lore, poisons, and a ghost, this is the perfect “Tox Tune” to post the weekend before smaccUS descends on the Windy City.

“Resurrection Mary,” which appeared on Ian Hunter’s 1996 album The Artful Dodger, recounts the famous Chicago ghost story involving about a vanishing hitchhiker who is periodically sited near the Resurrection Cemetery in southwest suburban Justice. Legend has it that the hitchhiker is the ghost of a young girl killed by an automobile in the late 1920s or early 1930s while trying to get away from her boyfriend.

As recounted by Wikipedia:

Since the 1930s, several men driving northeast along Archer Avenue between Willowbrook Ballroom and Resurrection Cemetery have reported picking up a young female hitchhiker. This young woman is dressed somewhat formally in a white party dress and is said to have light blond air and blue eyes. There are other reports that she wears a thin shawl, dancing shoes, carries a small clutch purse, and/or that she is very quiet. When the driver nears the Resurrection Cemetery, the young woman asks to be let out, whereupon she disappears into the cemetery. According to the Chicago Tribune, “full-time ghost hunter” Richard Crowe has collected “three dozen . . . substantiated” reports of Mary from the 1930s to the present.

As for toxicology, the narrator in the song relates that he  formerly worked for Mickey Finn, the legendary Chicago bartender who pioneered the use of chloral hydrate as a knockout drop. In addition, given the narrator’s drinking history as described in the first verse, the entire encounter with Resurrection Mary might have been an alcohol-related hallucination.

Watch as the Travel Channel retells the tale of Resurrection Mary:

And for more Chicago ghost stories:

Looking back: the first FOAMed meeting in the U.S.

FOAM mtg 2010

This photograph, from November 2010, documents what was to my knowledge the first #FOAMed get-together on U.S. soil. Gathered that evening at a tapas restaurant in San Francisco during the “Essentials of EM” conference were (from left to right):

It is truly amazing to realize that only four-and-a-half years later, 2000 foamheads from around the world are descending on Chicago for the 3-day festival of life and learning called smaccUS. A lot has happened in that short time, and I think it’s fair to say that the world of medical education has been revolutionized by social media. TPR is looking forward to meeting everyone coming into town this week.

What a short, strange trip it’s been!


Illustrated case report of phenol exposure



3.5 out of 5 stars

Phenol Toxicity Following Cutaneous Exposure to Creolin®:A Case Report. Vearrier D et al. J Med Toxicol 2015 Jun;11:227-231.


This paper is worth looking at for the excellent color photographs of the partial thickness skin burns induced by exposure to Creolin®, which contains carbolic acid (phenol), sodium hydroxide, and isopropanol.

A 9-year-old girl was brought to the emergency department because of respiratory distress and unresponsiveness. Symptoms came on quickly and started within 4 minutes of the mother pouring 8 oz Creolin® over the patients hair in an attempt to get rid of head lice. Some liquid made contact with the girl’s neck, back, shoulder, and upper arm.

On arrival at hospital the patient was intubated because of decreased level of consciousness. Exam showed erythema and hyper pigmentation over areas that contact the liquid. External decontamination was accomplished by sponging with soap and water. Brief runs of monomorphic ventricular tachycardia were treated with lidocaine. Endoscopy did not find any GI lesions, and the paper was extubated within 12 hours of exposure. Ultimately, 17% body surface area partial thickness burns were documented. Many of these areas desquamated after several days. When the patient was seen again in the emergency department 2 years after this incident, there no residual scarring was seen.

Some points from the paper:

  • Phenol is caustic, causes coagulative necrosis, and is rapidly absorbed through the skin.
  • Although scant and inconsistent data from some animal models suggest that decontaminating phenol exposure with isopropanol or low-molecular-weight propylene glycol offers improved outcome over soap and water, these are often not readily available.
  • Since phenol easily penetrates protective gloves commonly used in the emergency department, treating staff should use neoprene gloves or, if these are not available, put on double gloves and change them frequently.

Not much really new here, but the photographs are really impressive.

Case series: 11 hospital workers symptomatic after ingesting “synthetic marijuana” brownies

brownie3 out of 5 stars

Cluster of Acute Toxicity from Ingestion of Synthetic Cannabinoid-Laced Brownies. Obafemi AI et al. J Med Toxicol 2015 May 13 [Epub ahead of print]


This case series describes 11 patients brought to hospital after inadvertently ingesting brownies laced with the synthetic cannabinoid AM-2201.

All 11 patients were hospital workers who ingested brownies brought to work by a staff member. In each patient, symptoms started within an hour of ingestion and generally resolved within 2 to 4 hours (although two persons felt tired and dizzy for up to 10 hours post-ingestion.) The most common neurological manifestations included memory impairment (10/11) and “inappropriate giggling” (4/11.) All patients reported numbness and tingling, dry mouth, and lightheadedness. There were no gastrointestinal manifestations. All patients had negative routine urine drug screens.

Laboratory analysis of a remaining brownie was positive for AM-2201. No analytical tests were done on biological specimens.

Note that this report’s findings are not generalizable, since the next patient you see with exposure to a synthetic cannabinoid could have ingested an entirely different agent and/or a radically different dose. Your mileage may vary.

And of course, whenever we refer to marijuana brownies — or even synthetic marijuana brownies — we have to replay this clip:

Related post:

First case of cycle emesis associated with synthetic cannabinoids


[Photo of brownie from]

Podcast: Managing the crashing tox patient with ECMO

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As I wrote about in a recent column for Emergency Medicine News, extracorporeal membrane oxygenation (ECMO) may be the next big thing in managing the severely ill, crashing overdose patient in whom usual therapy is not working. On the new podcast posted today at the EDECMO website, Steve Aks and I got together over Skype with Joe Bellezzo, Zack Shinar, and Scott Weingart to discuss the potential benefits, as well as the potential risks and complications, involved in using ECMO in the sickest tox patients.

Some of the topics we discuss:

  • What overdose patients might benefit most from ECMO?
  • What vascular access is needed for ECMO?
  •  Would ECMO be effective in treating poisoning from agents such as carbon monoxide and cyanide that are not primarily cardiodepressants?
  • Should ECMO and lipid reduce therapy be done simultaneously?
  • Can hemodialysis be done safely in a patient on ECMO, and if so can the dialysis circuit be in series with the ECMO pathway?

To listen to the podcast, click here.

Here are links to some of the papers mentioned during our discussion, and even more recent literature:

Bellezzo J et al. Emergency physician-initiated extracorporeal cardiopulmonary resuscitationResuscitation 2012 Aug;83:966-70.

De Lange DW et al. Extracorporeal membrane oxygenation in the treatment of poisoned patients. Clin Toxicol 2013 Jun;51:385-393.

Escajeda JT et al. Successful treatment of metoprolol-induced cardiac arrest with high-dose insulin, lipid emulsion, and extracorporeal membrane oxygenationAm J Emerg Med 2015 Jan 16 [Epub ahead of print]

Johnson NJ et al. A Review of Emergency Cardiopulmonary Bypass for Severe Poisoning by Cardiotoxic DrugsJ Med Toxicol 2013 Mar;9:54-60

Lee HM et al. What are the adverse effects associated with the combined use of intravenous lipid emulsion and extracorporeal membrane oxygenation in the poisoned patient?  Clin Toxicol 2015;53:145-150.

Wang GS et al. Extracorporeal Membrane Oxygenation (ECMO) for Severe Toxicological Exposures: Review of the Toxicology Investigators Consortium (ToxIC)  J Med Toxicol 2015 May 27 [Epub ahead of print]