Salicylates cause a mixed acid–base disturbance of primary respiratory alkalosis and primary metabolic acidosis Drug absorption can be erratic, necessitating serial salicylate concentrations as part of the assessment Patients may present with either an alkalemia or acidemia initially Young children and patients with chronic toxicity may be more likely to demonstrate acidemia at initial evaluation Physical manifestations of salicylism include fever, tachypnea, nausea, vomiting, lethargy, slurred speech, and seizures Treatment is geared toward alkalinization of the serum and urine Hemodialysis is indicated for patients with persistent acidemia, altered mental status, or very elevated serum salicylate concentrations Current Evidence Salicylates (most commonly aspirin) continue to be a common cause of poisoning in children and adolescents Salicylism is the result of acute ingestion in about 60% of cases and chronic ingestion in the remaining 40% Clinical features of acute versus chronic salicylate intoxication often require a different management approach, depending on the manner of intoxication Several factors work in concert to make chronic salicylate intoxication so common The primary factor is aspirin’s elimination pattern As serum salicylate concentrations increase, the ability of the liver to metabolize the drug diminishes until predictable, first-order elimination kinetics are replaced by unpredictable, dose-dependent, zero-order elimination Thereafter, increments in dose are associated with disproportionate increases in serum salicylate concentration Also, much of aspirin elimination is through urinary excretion of unchanged drug Therefore, in the face of dehydration and decreased glomerular filtration, drug clearance is impaired further Finally, because aspirin is often prescribed for illnesses that may be associated with hepatic dysfunction, reduced biotransformation initiates the spiraling increase in serum concentration Unfortunately, because chronic salicylism is associated with nonspecific symptoms (e.g., fever, vomiting, tachypnea), diagnosis may be delayed until more striking signs of intoxication appear The direct effects of salicylates on metabolism are multiple Salicylates stimulate the medullary respiratory center, which leads to tachypnea and respiratory alkalosis—the hallmark of salicylism Metabolic disturbances are widespread and include CNS hypoglycemia, as well as abnormalities in lipid and