In this episode of Tox in Ten, host Elissa Moore (@ElissaMoore3) explores the evidence and recommendations surrounding intubation of the salicylate toxic patient.

The Cliff’s Notes Version:

This month’s podcast asks what do we do for patients with severe toxicity who are no longer protecting their airway or have severe respiratory fatigue?

1. Avoid intubation if at all possible.
2. When the decision is made to intubate take the time to prepare and limit the period of apnea/hypoventilation.
3. Bolus with several amps of bicarbonate prior to sedation.
4. Use appropriate ventilator settings to maximize your patient’s minute ventilation. Try to match their respiratory rate prior to intubation.
5. Closely monitor blood gasses and clinical status, making frequent adjustments as needed.
6. Consider early initiation of hemodialysis.

Articles Reviewed:

Greenberg, Michael I., Robert G. Hendrickson, and Maryann Hofman. “Deleterious effects of endotracheal intubation in salicylate poisoning.” Annals of emergency medicine 41.4 (2003): 583-584.

McCabe, Daniel J., and Jenny J. Lu. “The association of hemodialysis and survival in intubated salicylate-poisoned patients.” The American journal of emergency medicine 35.6 (2017): 899-903.

Stolbach, Andrew I., Robert S. Hoffman, and Lewis S. Nelson. “Mechanical Ventilation Was Associated with Acidemia in a Case Series of Salicylate‐poisoned Patients.” Academic Emergency Medicine 15.9 (2008): 866-869.