Lithium, Elemental

CAS RN: 7439-93-2

Treatment Overview

0.4.2 ORAL EXPOSURE
  • A) MANAGEMENT OF MILD TO MODERATE ORAL TOXICITY
    • 1) Perform early (within 12 hours) endoscopy in patients with stridor, drooling, vomiting, significant oral burns, difficulty swallowing or abdominal pain, and in all patients with deliberate ingestion. If burns are absent or grade I severity, patient may be discharged when able to tolerate liquids and soft foods by mouth. If mild grade II burns, admit for intravenous fluids, slowly advance diet as tolerated. Perform barium swallow or repeat endoscopy several weeks after ingestion (sooner if difficulty swallowing) to evaluate for stricture formation.
  • B) SEVERE ORAL TOXICITY
    • 1) Resuscitate with 0.9% saline; blood products may be necessary. Early airway management in patients with upper airway edema or respiratory distress. Early (within 12 hours) gastrointestinal endoscopy to evaluate for burns. Early bronchoscopy in patients with respiratory distress or upper airway edema. Early surgical consultation for patients with severe grade II or grade III burns, large deliberate ingestions, or signs, symptoms or laboratory findings concerning for tissue necrosis or perforation.
  • C) DILUTION
    • 1) Dilute with 4 to 8 ounces of water may be useful if it can be performed shortly after ingestion in patients who are able to swallow, with no vomiting or respiratory distress; then the patient should be NPO until assessed for the need for endoscopy. Neutralization, activated charcoal, and gastric lavage are all contraindicated.
  • D) AIRWAY MANAGEMENT
    • 1) Aggressive airway management in patients with deliberate ingestions or any indication of upper airway injury.
  • E) ENDOSCOPY
    • 1) Should be performed as soon as possible (preferably within 12 hours, not more than 24 hours) in any patient with deliberate ingestion, adults with any signs or symptoms attributable to inadvertent ingestion, and in children with stridor, vomiting, or drooling after inadvertent ingestion. Endoscopy should also be considered in children with dysphagia or refusal to swallow, significant oral burns, or abdominal pain after unintentional ingestion. Children and adults who are asymptomatic after inadvertent ingestion do not require endoscopy. The grade of mucosal injury at endoscopy is the strongest predictive factor for the occurrence of systemic and GI complications and mortality. The absence of visible oral burns does NOT reliably exclude the presence of esophageal burns.
  • F) CORTICOSTEROIDS
    • 1) The use of corticosteroids to prevent stricture formation is controversial. Corticosteroids should not be used in patients with grade I or grade III injury, as there is no evidence that it is effective. Evidence for grade II burns is conflicting, and the risk of perforation and infection is increased with steroid use.
  • G) STRICTURE
    • 1) A barium swallow or repeat endoscopy should be performed several weeks after ingestion in any patient with grade II or III burns or with difficulty swallowing to evaluate for stricture formation. Recurrent dilation may be required. Some authors advocate early stent placement in these patients to prevent stricture formation.
  • H) SURGICAL MANAGEMENT
    • 1) Immediate surgical consultation should be obtained on any patient with grade III or severe grade II burns on endoscopy, significant abdominal pain, metabolic acidosis, hypotension, coagulopathy, or a history of large ingestion. Early laparotomy can identify tissue necrosis and impending or unrecognized perforation, early resection and repair in these patients is associated with improved outcome.
  • I) PATIENT DISPOSITION
    • 1) OBSERVATION CRITERIA: Patients with alkaline corrosive ingestion should be sent to a health care facility for evaluation. Patients who remain asymptomatic over 4 to 6 hours of observation, and those with endoscopic evaluation that demonstrates no burns or only minor grade I burns and who can tolerate oral intake can be discharged home.
    • 2) ADMISSION CRITERIA: Symptomatic patients, and those with endoscopically demonstrated grade II or higher burns should be admitted. Patients with respiratory distress, grade III burns, acidosis, hemodynamic instability, gastrointestinal bleeding, or large ingestions should be admitted to an intensive care setting.
  • J) PITFALLS
    • 1) The absence of oral burns does NOT reliably exclude the possibility of significant esophageal burns.
    • 2) Patients may have severe tissue necrosis and impending perforation requiring early surgical intervention without having severe hypotension, rigid abdomen, or radiographic evidence of intraperitoneal air.
    • 3) Patients with any evidence of upper airway involvement require early airway management before airway edema progresses.
    • 4) The extent of eye injury (degree of corneal opacification and perilimbal whitening) may not be apparent for 48 to 72 hours after the burn. All patients with corrosive eye injury should be evaluated by an ophthalmologist.
  • K) DIFFERENTIAL DIAGNOSIS
    • 1) Acid ingestion, gastrointestinal hemorrhage, or perforated viscus.
0.4.3 INHALATION EXPOSURE
  • A) DECONTAMINATION
    • 1) Administer oxygen as necessary. Monitor for respiratory distress.
  • B) AIRWAY MANAGEMENT
    • 1) Manage airway aggressively in patients with significant respiratory distress, stridor or any evidence of upper airway edema. Monitor for hypoxia or respiratory distress.
  • C) BRONCHOSPASM
    • 1) Treat with oxygen, inhaled beta agonists and consider systemic corticosteroids.
0.4.4 EYE EXPOSURE
  • A) DECONTAMINATION
    • 1) Exposed eyes should be irrigated with copious amounts of 0.9% saline for at least 30 minutes, until pH is neutral and the cul de sacs are free of particulate material.
    • 2) An eye examination should always be performed, including slit lamp examination. Ophthalmologic consultation should be obtained. Antibiotics and mydriatics may be indicated.
0.4.5 DERMAL EXPOSURE
  • A) OVERVIEW
    • 1) DECONTAMINATION
      • a) Remove contaminated clothes and any particulate matter adherent to skin. Irrigate exposed skin with copious amounts of water for at least 15 minutes or longer, depending on concentration, amount and duration of exposure to the chemical. A physician may need to examine the area if irritation or pain persist.
0.4.2 ORAL EXPOSURE
  • A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    • 1) Most acute lithium overdoses may be safely managed with supportive care that includes: antiemetics for nausea and vomiting, intravenous normal saline hydration to enhance renal lithium elimination, and correction of any electrolyte abnormalities. For chronic toxicity, address underlying causes of decreased renal clearance, including intravenous fluids for dehydration or ceasing medications that impair renal function.
  • B) MANAGEMENT OF SEVERE TOXICITY
    • 1) Orotracheal intubation for airway protection should be performed if recurrent seizures, increasing somnolence or coma develop. Consider gastric lavage for recent, large ingestion if airway is protected. Whole bowel irrigation with polyethylene glycol may be considered in large ingestions, especially if a sustained-release formulation. Administer intravenous normal saline to enhance renal elimination of lithium (Goal: urine output of 2 to 3 mL/kg/hr). Intravenous fluids and vasopressors (dopamine, norepinephrine) may be needed to treat hypotension. Treat agitation, rigidity, seizures, hyperthermia, serotonin syndrome with sedation (benzodiazepines, propofol), and cooling measures; intubation and paralysis may be necessary with severe toxicity. Consider hemodialysis for patients with severe toxicity not responding to hydration, or congestive heart failure or renal insufficiency. Dysrhythmias are treated with standard ACLS protocols.
  • C) DECONTAMINATION
    • 1) PREHOSPITAL: Charcoal does not adsorb lithium well; it is not recommended.
    • 2) HOSPITAL: Consider gastric lavage in a patient with recent life-threatening ingestion, if airway is protected or patient is alert. Whole bowel irrigation with polyethylene glycol should be considered with a large ingestion or ingestion of a sustained-release product.
  • D) AIRWAY MANAGEMENT
    • 1) Intubate if unable to protect airway due to worsening agitation, somnolence or coma, or if respiratory distress develops.
  • E) ANTIDOTE
    • 1) None.
  • F) ENHANCED ELIMINATION
    • 1) Hemodialysis increases lithium clearance and decreases half-life. The decision to perform hemodialysis is largely clinical. The international expert Extracorporeal Treatments in Poisoning (EXTRIP) workgroup reviewed the available literature and despite a low quality of evidence recommended the following guidelines for extracorporeal treatment (ECTR) in patients with severe lithium toxicity with any of the following clinical conditions:
      • a) In the presence of a reduced level of consciousness, seizures, or life-threatening dysrhythmias irrespective of lithium concentration.
      • b) If kidney function is impaired and lithium concentration is greater than 4 mEq/L.
    • 2) ECTR was also suggested for patients with any of the following clinical conditions:
      • a) If lithium concentration is greater than 5 mEq/L, if confusion is present, or if the expected time to obtain a lithium concentration less than 1 mEq/L with optimal management is greater than 36 hours.
    • 3) DISCONTINUATION of ECTR is recommended:
      • a) In patients with apparent clinical improvement or lithium concentration less than 1 mEq/L.
      • b) After a minimum of 6 hours of ECTR if the lithium concentration is not readily available.
    • 4) Serum lithium levels typically rebound 6 to 12 hours after dialysis in chronically intoxicated patients due to equilibration with intracellular and CNS lithium stores. In order to determine the use of subsequent ECTR sessions, serial lithium concentrations should be determined over 12 hours after the cessation of ECTR. The preferred ECTR is intermittent hemodialysis, with an acceptable alternative being continuous renal replacement therapy (RRT), if intermittent hemodialysis is not available. Both continuous RRT and intermittent hemodialysis are equally acceptable after the first treatment.
  • G) PATIENT DISPOSITION
    • 1) HOME CRITERIA: Accidental ingestions in asymptomatic lithium naive patients who ingest less than the maximum daily dose (Children less than 6 years old: 900 mg/square meter/day; Children 6 to 12 years old: 30 mg/kg/day; Adults: less than 2400 mg) who have no synergistic co-ingestions may be monitored at home. Those chronically taking lithium that are accidentally exposed to additional doses needed to be evaluated on a case by case basis, but typically tolerate a double dose without significant effects.
    • 2) OBSERVATION CRITERIA: Patients with deliberate ingestions, symptomatic patients, children and adults with ingestions of greater than maximum daily dose, acute-on-chronic ingestions, unknown dosing errors in chronic patients, synergistic co-ingestions, or those with unclear history should be sent to a health care facility for evaluation and observation. Patients should be monitored until serum lithium concentration has peaked and is consistently declining and clinical condition is improved.
    • 3) ADMISSION CRITERIA: Patients with persistent or worsening gastrointestinal irritation, renal impairment, altered mentation, respiratory depression, dysrhythmias, unstable vital signs, or persistently rising serum lithium concentrations should be admitted. Intensive care admission is indicated for aggressive airway, cardiac monitoring, and emergent hemodialysis.
    • 4) CONSULT CRITERIA: Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity (agitation, hyperthermia, need for hemodialysis, respiratory depression, coma), concerns about decontamination, or in whom the diagnosis is not clear. Consult a nephrologist for emergent hemodialysis in patients with severe poisoning.
  • H) PITFALLS
    • 1) Patients with chronic toxicity often exhibit neurologic toxicity at levels lower than those with acute exposures. Close monitoring of electrolytes, renal function, urine output, neurologic exam, mental status, and temperature should be correlated with serial levels to assess efficacy of treatment. Anticipate early the need to transfer the patient to a higher level of care if unable to check serial lithium concentration, or if hemodialysis is not available. Diuretics should be avoided as they increase lithium reabsorption in the renal tubules.
  • I) PHARMACOKINETICS
    • 1) Well absorbed; peak concentrations within 2 to 5 hours. Lithium is not bound to plasma proteins. The volume of distribution is 0.79 L/kg. Primarily renal (8% to 98%) elimination. Initial half-life is 6 to 12 hours, slowing to 24 hours or greater due to slow redistribution from intracellular compartment. Nearly 80% of filtered lithium is reabsorbed in proximal tubule; reabsorption increases with sodium depletion or dehydration. Half-life in therapeutic dose is approximately 19 hours (14 to 24 hours).
  • J) TOXICOKINETICS
    • 1) Peak lithium concentrations delayed 4 to 17 hours after overdose of sustained release formulations. Half-life is shorter in acute overdose (10 to 20 hours) and prolonged in patients with chronic intoxication (mean 32 hours). Hemodialysis reduces half-life to 2 to 5 hours. Serum concentrations rebound after hemodialysis due to redistribution from intracellular compartments.
  • K) DIFFERENTIAL DIAGNOSIS
    • 1) Extrapyramidal effects from other medications, neuroleptic malignant syndrome, serotonin syndrome from other agents, sepsis, CNS infections, or intracranial catastrophes (massive hemorrhage or stroke).
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