Ten Fast Facts for Managing Lithium Toxicity in the ED Setting

1. Classic presentation

• Nausea, vomiting, lethargy, tremors, ataxia, nystagmus, hyperreflexia, seizures, myoclonus, hyperthermia, cardiovascular collapse

2. Rapid absorption in GI tract

• Activated charcoal unlikely to be effective

• Can consider whole bowel irrigation in acute overdose, especially if sustained release form

3. Toxicity in chronic users

• May be precipitated by renal failure, heart failure, sepsis, volume depletion (diuretic use, vomiting, diarrhea, decreased PO intake)

4. Slow movement in/out of CNS - serum levels do not predict CNS levels

• Acute toxicity - GI symptoms precede neurologic symptoms

• Chronic toxicity - Neurologic symptoms > GI

5. EKG findings:

• Long QT, flat/inverted T waves, bradycardia

6. First line treatment:

• Normal saline 20cc/kg bolus followed by NS @ 1-2x maintenance

7. When to dialyze:

• Severe toxicity - seizures, coma, life threatening arrhythmia

• By level - >4mEq/L if acute overdose vs >2.5mEq/L in chronic toxicity

• Or if renal failure, inability to tolerate large volume of fluid administration

8. Treatment of seizures

• Benzodiazepines > phenytoin

9. Disposition:

• Asymptomatic - monitor 4-6h, admit if level is >1.5mEq/L

• Mild - NS hydration 6-12h, can discharge if <1.5mEq/L

• Moderate - Admit

• Severe - Admit to ICU setting

10. Have low threshold to check lithium level on known lithium users

References:

Schneider, S, Cobaugh, D, Kessler, B. “Lithium” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eEds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016.