Salicylate Toxicity
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þ Toxic levels:
 -

þ Done nomogram:
 - developed back in 1970s for single ingestions
 - used first order kinetics, but salicylates exhibit zero-order and only
   after a while first-order kinetics.
 - based on 6-hour level from ingestion; some people may get very toxic even
   before 6 hours
 - useless per Dr. Shih
 - Toxicity per Done nomogram 6-hour levels:
  + severe: 90-120 mg/dL
  + moderate: 70-90 mg/dL
  + mild:  45-70 mg/dL

þ methyl salicylate OD:
 - can get massive toxicity from a teaspoon of methyl salicylate.

þ Alkalinization of Urine:
 - In salicylate toxicity, alkalinization of the urine is a
   mainstay of treatment.
 - aim for a urine pH of 7.50-8.0, but try also to maintain the
   arterial pH between 7.4 and 7.5. [emedicine.com -
   http://www.emedicine.com/emerg/topic514.htm.]
 - Avoid Diamox: Acetazolamide causes an alkaline diuresis, but is
   contraindicated in salicylate toxicity.  Why? Acetazolamide also
   alkalinizes the CSF, trapping salicylate in the CNS.  In animal models,
   acetazolamide dramatically increases the mortality of salicylate toxicity.
   Ref: Tintinalli 3rd ed. p 591

þ Indications for hemodialysis for salicylate intoxication:
 - renal failure
 - CHF (relative)
 - noncardiogenic pulmonary edema
 - persistent CNS disturbances
 - progressive deterioration in VS
 - severe acid-base or electrolyte imbalance, despite appropriate treatment
 - hepatic compromise with coagulopathy (increased PT)
 - salicylate level > 100 mg/dL (acute)
   [Goldfrank's Toxicologic Emergencies, 54E, Appleton & LAnge, 1995.]