poisoning by aspirin

1. Aspirin Toxicity
2017
PREPARED BY:
MOHAMMED SABRI
BASSIMA MAJEED
SUNDAY | 10 December

2. University of Duhok
College of health science
Medical laboratories science
Report title:Aspirintoxicity
Objects:
- Aspirin medicationandits uses
- Common side effects of aspirin
- Aspirintoxicity.
- Pharmacokinetics
- Mechanismof toxicity
- Common causes Of AspirinToxicity
- Symptoms Of AspirinToxicity
- Acute and chronic toxicity
- Medical care
- Diagnosis of Aspirin toxicity
- Laboratory markers
- Self-care inAspirintoxicity
- Treatment Of AspirinToxicity
- Medications used
- Prevention

3. ASPIRIN
What is Aspirin:
Aspirin, also known as acetylsalicylic acid (ASA), is a medication
used to treat pain, fever, or inflammation. Specific inflammatory
conditionsin which aspirin is used
includeKawasaki disease,
pericarditis, and rheumatic fever.
Aspirin given shortlyafter a heart
attack decreases the risk of death.
Aspirin is also used long-term to
help prevent heart attacks, ischemic
strokes, and blood clots, in people
at high risk. Aspirin may also
decrease the risk of certain types of
cancer, particularlycolorectal
cancer. For pain or fever, effects typically begin within 30 minutes.
Aspirin is a non-steroidal
Anti-inflammatory drug (NSAID) and works similar to other
NSAIDs but also suppresses the normal functioning of platelets.
form of trade Aspirin The chemical structure of Aspirin

4. history
Sodium salicylate was not often popularthough, because it
irritated the stomach. However, in 1897, Felix Hoffman changed
the face of medicine forever. Hoffman was a German chemist
working for Bayer. He had been using the common pain reliever of
the time, sodium salicylate, to treat his father's arthritis. The
sodium salicylate caused his father the same stomach troubleit
caused other people, so Hoffman attempted to create a less acidic
salicylate formula. His work led to the synthesis of acetylsalicylic
acid, or ASA. This soon became the pain reliever of choice for
doctorsaround the globe.
In the 1970s, British pharmacologist John Vane, PhD, began
studying how aspirin works to relieve pain and reduce fever. Vane
and his colleagues found that aspirin inhibits the release of a
hormone-likesubstance called prostaglandin. This chemical helps
regulate bloodvessel elasticity and changes the functioning of
blood platelets. Thus aspirin can affect blood clottingand ease
inflammation.
fast facts on aspirin
 Aspirin is one of the most widely used medicationsin the world.
 It comes from salicylate, which can be found in plantssuch as willow
trees and myrtle.
 Aspirin was the first non-steroidalanti-inflammatorydrug (NSAID) to
be discovered.
 It interacts with a number of other drugs, includingwarfarin and
methotrexate.

5. Common side effects of Aspirin
The Common side effects of Aspirin
include an upset stomach. More significant
side effects commonly include stomach
ulcers, stomach bleeding, and worsening
asthma. Bleeding risk is greater among
those who are older, drink alcohol,take
other NSAIDs or are on blood thinners.
Aspirin is not recommended in the last part
of pregnancy.
It is not generally recommended in children with infections because of the
risk of Reye's syndrome. High doses may result in ringing in the ears.
Like all other medications overdose of the aspirin will lead to poisoning and it is
called Aspirin toxicity

6. ASPIRIN TOXICITY
Definition
Salicylate poisoning is the result of ingestion of, or (rarely) topical
exposure to, chemicals metabolised to salicylate. Poisoning may
occur because of acute or chronicsalicylate exposure and is also
characterised by acid-base disturbances, electrolyteabnormalities,
and CNS effects. The most common source of salicylate poisoning
is aspirin itself (acetylsalicylic acid), which is rapidly hydrolysed
to salicylate in the GI tract and bloodstream. Acutetoxicity may
occur after ingestion of a single dose of aspirin or the equivalent of
>150 mg/kg or >6.5 g. [1] Chronic poisoning tends to occur as a
result of repeated exposure to high-dose aspirin or equivalent (150
mg/kg/day).

7. Toxic effect usually appears after ingestion of:
- Less than 150 mg/kg - no symptoms to mild toxicity.
- Ingestions of 150-300 mg/kg - mild to moderate toxicity
- Ingestions of 300-500 mg/kg - serious toxicity
- Greater than 500 mg/kg - potentially lethal
After ingestion
Absorbed rapidly by passive diffusion in the intestines
Reaching In the blood, a large percentage of aspirin is
hydrolysed to salicylic acid by aspirin-splittingenzyme then
Salicylic acid is equallydistributed into all tissues and tissue
fluids of the body within 30 minutes and completelyexcreted
unchanged within 36 hours
PHARMACOKINETICS
- Absorbed rapidly by passive diffusion.
- 90 % Binds to albumin .
- Metabolized by the liver. (hepatic conjugation with
glycin or glucuronic acid).
- Excreted in the urine (PH dependent).

8. Mechanism of toxicity
Salicylates impair cellular respiration by uncoupling oxidative
phosphorylation. They stimulate respiratory centers in the medulla,
causing primary respiratory alkalosis. because of the hyperventilation
induced by salicylates. Kidneys compensate for this alkalosis buy
increasing the excretion of sodium and potassium bicarbonate
Sodium bicarbonate is often used to increase the excretion of the
Salicylates .Treat metabolic acidosis with intravenous sodium bicarbonate
Drugs which are weak acids (e.g. salicylates) exist in a state of
equilibrium between their ionised and un-ionised form By increasing the
systemic pH with sodium bicarbonate more of the salicylate is trapped in
its ionized form in the extra-cellular fluid resulting in enhanced renal
excretion.
Therefore sodium bicarbonate should be administered to correct any
acidosis (arterial pH should not rise above 7.6) and to alkalinise the urine
(optimum pH 7.5-8.5) but It is very difficult to produce an alkaline pH if
the patient is hypokalaemic as hydrogen ions tend to be excreted with the
bicarbonate instead of potassium. Therefore the potassium should be kept
at the upper end of normal

9. The common causes of aspirin toxicity
Aspirin poisoning can be classified as either Intentional or accidental
1- Intentional: For a variety of reasons, some people intentionally
ingest poisons or poison others. Some reasons include the
following:
 To commit suicide
 To commit murder
 To gain personal attention
 To commit child abuse
2- Accidental
 Accidental poisonings usually affect children.. This decrease is
attributed to the Poison Prevention Packaging Act and to poison
prevention publicity.
 The most common sources of accidental poisoning were plants,
various types of cleaners (soaps, detergents, and household cleaners),
vitamins and minerals, and aspirin. Aspirin is no longer the most
common cause of accidental poisoning. This is probably because of
child-resistant packaging.
 Inappropriate dosing in children and elderly people: Hundreds of
medications available both over-the-counter and by prescription
contain aspirin or aspirin-like substances. Unintentional aspirin
poisoning can result if these medications are taken in combination, in
inappropriate doses, or over a long time period. This is especially
likely to occur in older people with chronic health problems.

10. Aspirin Poisoning Symptoms
The earliest symptoms of acute aspirin poisoning may include ringing in
the ears (tinnitus) and impaired hearing. More clinically significant signs
and symptoms include rapid breathing (hyperventilation), vomiting,
dehydration, fever, double vision, and feeling faint.
Later signs of aspirin poisoning, or signs of more significant poisoning,
include drowsiness or confusion, bizarre behavior, unsteady walking, and
coma.
The abnormal breathing caused by aspirin poisoning is usually rapid and
deep. Vomiting may occur 3-8 hours after taking too much aspirin.
Serious dehydration may occur from hyperventilation, vomiting, and
fever.
Aspirin poisoning signs and symptoms can range from minor to severe.
 Mild to moderate: Deep and rapid breathing (hyperpnia) sometimes
with lethargy (abnormal drowsiness)
 Moderate: Severe deep and rapid breathing, prominent nervous
system disturbances, such as marked lethargy or excitability,but no
coma or convulsions
 Severe: Severe deep and rapid breathing, coma, sometimes with
convulsion
Factors Influencing Salicylate Toxicity
- Dose
- Age Of Victim
- Renal Function
- Dehydration

11. Assessing Salicylate Poisoning fromClinical Evaluation
two types of aspirin toxicity which are :
- Chronic
- Acute

12. When to Seek Medical Care
if minor symptoms of aspirin overdose are experienced, call the doctor
who prescribed the medication to see if the medication should be stopped
or the dosage reduced. Minor symptoms include ringing in the ears, dry
mouth, and dizziness.
for all other symptoms, call 911, (the local emergency phone number or
Poison Control) immediately. Also consider transporting the affected
person directly to a hospital's emergency department for evaluation.
Serious symptoms include the following:
 Agitation, fever, convulsions, collapse,confusion, coma
 Low blood pressure
 Rapid heart rate
 Rapid breathing
 Wheezing
 Vomiting and nausea
 Bleeding
 Hallucinations
 Drowsiness
Get emergency help immediately if any of the following symptoms occur
with aspirin overdose:
 Any hearing loss
 Any abnormalbleeding
 Confusion
 Convulsions(seizures)
 Dizziness (severe)
 Drowsiness (severe)
 Excitement or nervousness (severe)
 Fast or deep breathing

13.  Hallucinations(seeing, hearing, or feeling things that are not there)
 Headache (severe or continuing)
 Increased sweating
 Nausea or vomiting (severe or continuing)
 Ringing or buzzing in the ears (continuing)
 Sweating
 Unexplainedfever
 Unusual thirst
 Vision problems
Aspirin PoisoningDiagnosis
The doctor will take a history and perform a physical examination to look for
evidence of poisoning. The doctor will order laboratory tests to look for damage to
organ systems that can be harmed by aspirin overdose and, depending on the
timing, also to check for the level of aspirin in the bloodstream.
 The initialassessment of all poison victims follows the principlesof
basic and advancedcardiac life support. The doctor will make sure
the patient is able to breathe, and will check vital signs including
body temperature. The doctor will check alertness by asking the
patient to respond to questions. If the patientis unconscious, the
doctor will give oxygen and perhaps use machines to help the
patient breathe.
 Blood will be taken for lab testing. One bloodtest will measure the
amount of salicylate, the active ingredient in aspirin, in the blood.
Sometimes the blood level of salicylate can increase over time even
though an individualhasnot taken any more aspirin. This may
indicatethe person has taken coated tablets or sustained-release
tablets, which release salicylateinto the bloodstream slowly.

14.  The doctor will make treatment decisionsbased on the dose of
active ingredient ingested, the time over which it was ingested, age,
the symptoms, and acid-base status. Acid-base status is the balance
of acid and base in the blood. Aspirin may change this balance
quickly toward more acidic, so the doctor will monitor this to guide
treatment.
Acute aspirin or salicylates overdose or poisoning can cause initial
respiratory alkalosis though metabolic acidosis ensues thereafter. The
acid-base, fluid, and electrolyte abnormalities observed in salicylate
toxicity can be grouped into three broad phases:
 Phase I: Characterized by hyperventilation resulting from direct
respiratory center stimulation, leading to respiratory alkalosis and
compensatory alkaluria. Potassium and sodium bicarbonate are
excreted in the urine. This phase may last as long as 12 hours.
 Phase II: Characterized by paradoxic aciduria in the presence of
continued respiratory alkalosis occurs when sufficient potassium has
been lost from the kidneys. This phase may begin within hours and
may last 12–24 hours.
 Phase III: Characterized by dehydration, hypokalemia, and
progressive metabolic acidosis. This phase may begin 4–6 hours after
ingestion in a young infant or 24 hours or more after ingestion in an
adolescent or adult.

15. Laboratory markers:
1. Serumsalicylate:
- Low serum levels early after acute ingestion do not preclude
toxicity .
- Levels should be obtained every 2 hours until a decrease is noted
on two consecutive measurements.
- Acute ingestions of non–enteric-coatedaspirin should result in
peak serum levels by 6 hours after ingestion. A delayed increase
may be seen in patients with a salicylate pharmacobezoar, patients
who have ingested enteric-coatedor sustained-releasedproducts
(due to delayed absorption),and patients with worsening acidosis.
- Acute toxicity, levels ranging from 31 to 100 mg/dL
- Chronictoxicity, toxic levels may be as low as 30 to 40 mg/dL
2.Urinalysis:
- PH.
- ketones.
- Glucose.
- 10% ferric chloride test (100% sensitive, 71%specific)
3. Bloodglucose:
- Hypoglycemia
- Normal
- Hyperglycemia
4. Urea& Electrolytes:

16. - Hypokalemia.
- Hyponatremia.
- Urea: elevated.
5. Creatinine:
- Elevated.
6. ABG
7. CXR
8. ECG
9. Abdominal imaging:
- Suspicionof aspirin concretion & pharmacobezoar.
- US, CT, Endoscopy.
10. Hepatic, hematologic, and coagulation profiles - Obtain for
patients with clinical evidence of moderate to severe toxicity.
Aspirin Poisoning Self-Care at Home

17. If a drug overdose is discovered or suspected, and the victim is
unconscious, having convulsions, not breathing, or is otherwise seriously
ill, call 911 immediately (or the local emergency phone number) for
medical help.
If the person who took the drug is not having symptoms, do not wait to see
if symptoms develop. Call the local poison control center immediately. It
is a good idea to post the telephone number of the local poison control
center near the phone. This information can be found at: American
Association of Poison Control Centers. Or call (800) 222-1222 if you have
a poisoning emergency.Providing as much information as possible to the
poison control center can help determine what the next course of action
should be. These questions are not unique to aspirin poisoning, but are
used for almost all cases of poisoning.
The poison control center, paramedics, and emergency department staff
will want to know the following information:
 What medicationwas taken? Try to locate the medication's
container.
 Precisely what is the medicationthat was taken and how much is
left in the bottle?
 How much of the medicationwas taken?
 When was the medication taken?
 Was the medicationtaken with alcoholor any other drugs or
chemicals?
 What is the person's age?
 What symptoms are present?
 Is the person conscious?
 Is the person breathing?
 What medical conditionsdoes the person have?
Although ipecac syrup was used commonly in the past to make a patient vomit, it is rarely recommended today . It would not be
suggested in aspirin poisoning due to the chance that the patient might develop altered mental status or convulsions.
Aspirin Poisoning Treatment

18. The treatment of aspirin poisoning has three objectives:
1. To prevent further absorption of aspirin into the body
2. To correct dehydrationand acid-base abnormalities
3. To reduce the amount of salicylate within the body by increasing the
rate at which the body can get rid of it
Gastric lavage may be beneficial, unless contraindicated, up to 60 minutes
after salicylate ingestion. Warmed (38 C or 100.4 F) isotonic sodium
chloride solution may be used. The airway should be protected before
gastric lavage.
Dialysis is another way to reduce the amount of salicylate in the body. The
same technique that helps patients with kidney failure rid their bodies of
toxins can also be used to quickly eliminate aspirin from the body of a
person who has been poisoned with aspirin.
Many doctors recommend a toxicologist be consulted for aspirin overdose.
Medications for Aspirin Poisoning
Activated charcoal: To prevent more absorption, the doctor may give
charcoal to absorb the salicylate from the stomach. A laxative may be
given with the activated charcoal to move the mixture through the
gastrointestinal system more rapidly. People who have been severely
poisoned may be given repeated doses of activated charcoal.
IV fluids: Dehydration occurs early in aspirin poisoning. To correct
dehydration, the doctor will start an IV to correct this imbalance. The
doctor will also work to correct imbalances in the body's blood
chemistries.

19. Alkaline diuresis: This is a way to reduce the amount of salicylate in the
body. Alkaline diuresis is the process of giving a person who has been
poisoned compounds that alter the chemistry of the blood and urine in a
way that allows the kidneys to remove more salicylate. Specifically,
sodium bicarbonate is given via IV to make the blood and urine less acidic
(more alkaline), which encourages the kidneys to capture more salicylate that can leave the
bodythrough the urine. Sometimes, other compounds, suchas potassium, also have to be given
to help with this process and help prevent hypokalemia.
AspirinPoisoningOtherTherapy
The emergency physician may have to perform other procedures or give
other medications as supportive care in the case of dangerous aspirin
overdose. These actions may include the following:
 Placing a breathing tube (intubation)and assisting breathing with a
ventilatorfor a person who is agitated, in a coma, who cannot
protect their own airway, or for whom mechanicalbreathing could
be helpful
 Placement of a catheter into the bladder to monitor urine output
and frequently check the acidity(pH) of the urine
 Administrationof other medicationsas may be needed to treat
agitation,convulsions(seizures), or other complicationsof aspirin
poisoning

20. Aspirin PoisoningNext Steps
 Patients with major signs and symptoms (for example, neurological,
cardiopulmonary,andmetabolic) may be admitted to an intensive
care unit under the care of a medical toxicologist, if available.
Psychiatric service personnel may be consulted for patientswith
intentionaloverdose.
 Patients with minorsigns and symptoms (for example, tinnitusand
nausea) may be admitted to an extended care observationalunit or
medical floor.
 The followingpatientswill be admittedto the hospital,regardless of
salicylatelevels:
o Infants and elderly persons
o Individualswith long-term salicylism
o Those with ingestionsof sustained-release products
Aspirin PoisoningFollow-up
People with acute, single ingestions of non-entericcoated aspirin of less
than 150 mg/kg who have no symptoms and have a nontoxic aspirin level
after 6 hours may be released from the hospital. All others with aspirin
poisoning will likely be treated in the emergency department, then
hospitalized for further treatment and observation.
 Psychiatric and medical follow-up may be recommended.
 Careful monitoringof medicationintake will be recommended.
 Tests to monitor kidneyfunction may be ordered periodicallyafter
hospitaldischarge, especiallyin the elderly.

21. Aspirin PoisoningPrevention
Prescription medications should be used according to a doctor's and
pharmacist's directions.
 Never take a medicine prescribed for someone else.
 To protect children from accidentaldrug overdose, all medications
should be stored in containerswith child-resistant caps. All
medicationsshouldbe out of sight and out of reach of children,
preferably in a locked cabinet.
 Take suicidal threats seriously.
 Never give or take medication in the dark.
 Always tell the doctor of any previousside effects or adverse
reactions to medicationas well as any new or unusualsymptoms
that occur.
 Never take more than the recommended or prescribed dose of a
medication.
 Inform your doctor aboutall the medicationsyou are taking. Be sure
to mention over-the-counter medications.
Prevention
A bottle of aspirin with a child-resistant cap
bearing the instruction "push down and turn to
open"
Efforts to prevent poisoning include child-resistant packaging and a lower number of pills per
package