Lithium Toxicity CCC
OVERVIEW
- acute overdose is usually benign if adequate hydration is maintained and renal function is normal
- chronic toxicity can be difficult to manage and result in devastating neurotoxicity
CLINICAL FEATURES
- acute ingestion or chronic accumulation
- CNS: confusion -> coma, cerebella symptoms, seizure, basal ganglia symptoms (choreiform movements, Parkinson-like)
- GIT: nausea, vomiting, bloating
- CVS: syncope
- RENAL: polyuria, polydipsia, renal insufficiency
- NEUROMUSCULAR: peripheral neuropathy, myopathy
- ENDOCRINE: hypothermia, hyperthermia
INVESTIGATIONS
- Lithium level:
0.7-1.2mEq/L (therapeutic)
> 1.5mEq/L (toxic)
levels can be very high following acute ingestion, but do not correlate with outcome - as clinical features determine
MANAGEMENT
Resuscitation
- A – impaired LOC -> intubate
- consider whole bowel irrigation for massive acute ingestion
- activated charchoal does not bind
- Liberal fluid resuscitation with normal saline
Electrolytes and Acid-base
- Avoid hyponatraemia as this will decrease lithium clearance
Specific Interventions
- fluid therapy
- renal clearance = 10-40mL/min
- CRRT clearance = 20mL/min
- haemodialysis if level > 3.5, severe symptoms or if conservative treatment doesn’t result in a level < 1.0 in 24 hrs (clearance = 70-170mL/min)
Underlying Cause
- infection
- volume depletion
- gastroenteritis
- overdose
- chronic kidney disease
- drugs: NSAIDS, diuretics, cyclosporine, tetracyclines
- decreased Na+ intake
- anorexia
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC