Lithium Toxicity – Evaluation and Management

Immediate-release lithium:  peak in 1-2 hours
Sustained-release lithium:  peak in 4-6 hours
Initial labs:  screen for co-ingestants (ASA, APAP, etc.), glucose, EKG, pregnancy test.
Levels:  q 2-4 hours while treating with IVF or hemodialysis; can go to every 6-8 hours once trend is improving.
Mild toxicity:  lethargy, tremors, slurred speech.
Moderate-severe toxicity:  severe lethargy, coarse tremors, clonus
Chronic toxicity:  check TSH; monitor for nephrogenic diabetes insipidus (sodium q 6-12 hours for 24-48h), don’t make hyperNa with IVF!
Treatment:
IVF (normal saline) – keep Na as normal as possible to maximize renal function and excretion.
No role for charcoal
Whole bowel irrigation if SR products taken and pt is asymptomatic and awake.
Consider dialysis if:  serum concentrations > 4 regardless of sxs; or > 2.5 with moderate-severe symptoms.
Safe to discharge once levels less than 1.5.
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