Avoid intubation unless absolutely necessary!
Very difficult to achieve adequate minute ventilation on vent
Inadequate minute ventilation → ↑ respiratory acidosis → ↑ ASA crossing BBB
While on ventilator, adjust RR to maintain goal serum pH 7.5 - 7.59
Indications for intubation: hypoxemia or hypoventilation
Give sodium bicarbonate 50-100 meq prior to intubating
Very difficult to achieve adequate minute ventilation on vent
Inadequate minute ventilation → ↑ respiratory acidosis → ↑ ASA crossing BBB
While on ventilator, adjust RR to maintain goal serum pH 7.5 - 7.59
Indications for intubation: hypoxemia or hypoventilation
Give sodium bicarbonate 50-100 meq prior to intubating
Inadequate minute ventilation → ↑ respiratory acidosis → ↑ ASA crossing BBB
While on ventilator, adjust RR to maintain goal serum pH 7.5 - 7.59
Acute lung injury may lead to high O2 requirements
Hypotension is common due to systemic vasodilation
IVF +/- K+ (if no cerebral edema, no pulmonary edema)
If these are present consider pressors
If these are present consider pressors
Charcoal 1g/kg up to 50g PO
Effectively absorbs ASA
Give multiple doses if tolerated
25g PO q2hr x 3 doses OR 50g q4hr x 2 doses after initial dose
Whole-bowel irrigation
Consider for ingestion of large amount of enteric-coated or extended-release forms
Effectively absorbs ASA
Give multiple doses if tolerated
25g PO q2hr x 3 doses OR 50g q4hr x 2 doses after initial dose
25g PO q2hr x 3 doses OR 50g q4hr x 2 doses after initial dose
Consider for ingestion of large amount of enteric-coated or extended-release forms
Give D50 to altered patients regardless of serum glucose concentration
Except for fluids used for initial resuscitation, all IVF should be D5W
ASA<unk>  impairs glucose metabolism
ASA<unk>  impairs glucose metabolism
Not a substitute for dialysis in severe salicylism
Continuous IV infusion of sodium bicarbonate is indicated even in the presence of mild alkalemia from the early respiratory alkalosis per 2013 ACMT guidelines
Alkalemia from respiratory alkalosis is NOT a contraindication to NaHCO3 treatment
Mechanism
Traps ASA in blood and in renal tubules
Increases elimination; prevents diffusion across BBB
Indications
ASA>35 or suspect serious<unk> 
Goals
Blood pH goal: = >7.5, <7.6
Urine pH goal: 7.5-8
Monitor serum electrolytes (to include potassium and magnesium) q2-4hrs during urine alkalinization
HCO3 will drive potassium into cells during drip
Ensure replacement of magnesium and potassium, as urine will not alkalinize otherwise
Dosing
NaHCO3 1-2mEq/kg IV bolus; then 3amp bicarb in 1L D5W at 2-3mL/kg/hr
Maintain urine pH >7.5
Traps ASA in blood and in renal tubules
Increases elimination; prevents diffusion across BBB
Increases elimination; prevents diffusion across BBB
ASA>35 or suspect serious<unk> 
Blood pH goal: = >7.5, <7.6
Urine pH goal: 7.5-8
HCO3 will drive potassium into cells during drip
Ensure replacement of magnesium and potassium, as urine will not alkalinize otherwise
NaHCO3 1-2mEq/kg IV bolus; then 3amp bicarb in 1L D5W at 2-3mL/kg/hr
Maintain urine pH >7.5
Maintain urine pH >7.5
Bolus during intubation
If intubation is required, consider administration of sodium bicarbonate by IV bolus at the time of intubation to maintain a blood pH of 7.45-7.5 over the next 30 minutes
If intubation is required, consider administration of sodium bicarbonate by IV bolus at the time of intubation to maintain a blood pH of 7.45-7.5 over the next 30 minutes
Indicated for:
Altered mental status
Seizure
Pulmonary edema
Coagulopathy
Inability to tolerate volume load from bicarb drip (e.g. CHF)
New hypoxemia
pH ≤7.20
High ASA levels
Initial levels
>7.2 mmol/L (100mg/dL)
>6.5 mmol/L (90mg/dL) in the setting of AKI
After standard therapy
>6.5 mmol/L (90mg/dL)
>5.8 mmol/L (80mg/dL) in the setting of AKI
Initial levels
>7.2 mmol/L (100mg/dL)
>6.5 mmol/L (90mg/dL) in the setting of AKI
After standard therapy
>6.5 mmol/L (90mg/dL)
>5.8 mmol/L (80mg/dL) in the setting of AKI
>7.2 mmol/L (100mg/dL)
>6.5 mmol/L (90mg/dL) in the setting of AKI
>6.5 mmol/L (90mg/dL)
>5.8 mmol/L (80mg/dL) in the setting of AKI
Salicylate toxicity
Lactic acidosis
Chlorate toxicity
Sepsis, shock, liver disease, CO, CN, metformin, methemoglobin
Organophosphate toxicity
Short bowel syndrome
Thallium toxicity
Propylene glycol infusions for lorazepam and phenobarbital