›Sodium bicarbonate infusion
›Mix 150 mEq sodium bicarbonate in 1 L D5W
›Infusion rate 150 mL/hour to 250 mL/hour
›Adjust to urine pH goal 7.5 to 8.0
›Serum pH target
›7.45 to 7.55
›Monitoring frequency
›Electrolytes every 2 hours initially
›Blood gas every 2 hours initially
›Urine pH checks every 1 hour to 2 hours
›Potassium repletion
›Target potassium 4.0 mmol/L to 4.5 mmol/L
›Potassium chloride IV or PO as clinically appropriate
›Avoid dextrose-free bicarbonate solutions if hypoglycaemic risk
›Rationale
›Hypokalaemia drives renal H+ secretion
›Acidic urine traps salicylate in non-ionised form less effectively
›Fluids and temperature control
›Isotonic crystalloid
›Volume depletion correction
›Avoid fluid overload if pulmonary oedema
›Dextrose therapy
›Altered mental status with normal glucose
›Dextrose 10% infusion to maintain euglycaemia
›Repeat bedside glucose monitoring
›Hypoglycaemia
›Dextrose 25 g IV for adults
›Dextrose 0.5 g/kg IV for paediatrics
›Hyperthermia management
›External cooling
›Evaporative cooling
›Ice packs to axilla and groin
›Sedation for severe agitation driving heat production
›Seizure and agitation control
›Benzodiazepines
›Lorazepam IV 0.1 mg/kg
›Typical adult 2 mg to 4 mg
›Repeat every 5 minutes as needed
›Diazepam IV 0.15 mg/kg to 0.2 mg/kg
›Refractory seizures
›Levetiracetam IV 60 mg/kg
›Maximum 4500 mg
›Phenobarbital IV 15 mg/kg to 20 mg/kg
›Intubation strategy when unavoidable
›Pre-intubation preparation
›Bicarbonate bolus immediately prior
›Maximise pre-oxygenation without suppressing ventilation
›Plan for immediate high minute ventilation post-intubation
›Post-intubation targets
›Maintain pre-intubation PaCO2 or lower
›Avoid normalising PaCO2
›Avoid permissive hypercapnia
›Immediate blood gas check after stabilisation
›Paralysis and sedation risk
›Apnoea interval minimisation
›Avoid long apnoea during induction
›Haemodialysis indications
›Severe clinical features
›Altered mental status
›Seizure
›Pulmonary oedema
›Shock
›Acid-base failure
›pH < 7.2 despite bicarbonate therapy
›Worsening acidaemia trend
›Renal failure
›Oliguria
›Rising creatinine with inability to alkalinise
›Concentration thresholds supporting dialysis
›Acute ingestion 7.2 mmol/L (1000 mg/L) or higher
›Acute ingestion 5.8 mmol/L (800 mg/L) or higher with symptoms
›Chronic ingestion 4.3 mmol/L (600 mg/L) or higher
›Lower threshold with any severe clinical feature
›Rebound monitoring
›Repeat salicylate concentration 2 hours after dialysis ends
›Continue alkalinisation until stable downtrend and clinical recovery