Module 6: Special Considerations in Salicylate Toxicity

6.1 Pediatric and Geriatric Considerations

Pediatric patients warrant careful dosing adjustments for their low body mass and immature organ function. Reduced protein binding facilitates greater free drug levels. The enhanced permeability of the blood-brain barrier predisposes to neurotoxicity. Exchange transfusion is an alternative when hemodialysis is not feasible.

Elderly patients with declining renal function require dose reductions. A lower threshold for hemodialysis, such as with levels exceeding 40 mg/dL, should be used. Meticulous medication reconciliation and avoidance of drug interactions is key. Careful monitoring to recognize chronic toxicity is needed as presentations can be nonspecific.

6.2 Management of Complications and Comorbidities 

Pulmonary edema may require diuretics or mechanical ventilation with high positive end-expiratory pressure (PEEP). Cerebral edema can be managed with osmotic diuretics, hyperventilation, hypothermia and elevating the head. Rhabdomyolysis may warrant aggressive IV fluid resuscitation and urine alkalinization. Coagulopathy requires holding anticoagulants and giving Vitamin K. Dextrose and potassium repletion addresses hypoglycemia and hypokalemia respectively.

Underlying liver disease reduces clearance of salicylate. Concurrent renal dysfunction limits the use of alkalinization and necessitates early hemodialysis. Pre-existing cerebral or pulmonary disease reduces the reserve to compensate for further insult. These comorbidities require prompt intervention and close monitoring for deterioration. 

6.3 Long-Term Care and Follow-up for Patients

Survivors of significant salicylate toxicity should limit or avoid future use given their susceptibility. Psychiatric evaluation for self-harm risk and prevention education is needed after intentional overdoses. Outpatient lab monitoring, repeat ECGs and neurological evaluations are sometimes necessary to ensure complete resolution and assess for long-term sequelae. Audiology referral is recommended if tinnitus or hearing loss persists. Follow up care coordination with social work, addiction medicine and primary providers is ideal.