Don't Slow Me Down! Airway Management in Salicylate Toxicity

#1 Rule: Do NOT take control of the patient’s airway unless absolutely necessary!

  • Hyperventilation in these patients is protective to compensate for a severe metabolic acidosis caused by salicylic acid. Hyperventilation is not a reason for intubation!
  • If the patient is unable to maintain an adequate minute ventilation or cannot protect their airway then you will likely need to intubate.
  • Be aware that sedation and paralysis can rapidly worsen acidemia in these patients while we attempt to obtain control of the airway, so be ready!

Tips for Airway Management:

#1: Avoid intubation

#2: Maintain a normal or slightly alkalemic blood pH (7.45-7.50) prior to and post intubation. Way to achieve this include:

  • Administer sodium bicarbonate
  • Bag valve mask hyperventilation

#3: Post intubation set a high minute ventilation, start by matching the patient’s pre-intubation rate
#4: Check an ABG and adjust the ventilator as necessary to adequately compensate for the metabolic acidosis


For further information on salicylate toxicity: Americal College of Medical Toxicology: Management Priorities in Salicylate Toxicity