see also: - [Murray Lithium](x-devonthink-item://C8AE745C-C96E-4AEF-9010-D441840C6DF4?page=285) - [Austin Lithium acute](x-devonthink-item://348DC41D-EBE2-4A3C-B0D9-474B6B406A26) - [Austin Lithium chronic](x-devonthink-item://F1B4AF23-1245-45FC-9EDE-D49A30D7FCF2) - [Cameron Lithium Acute](x-devonthink-item://10DC3BB1-027C-40D6-BDB3-4AF0C6B160E6?page=824) - [bear digixin vs lithium table](bear://x-callback-url/open-note?id=220FA6A3-A8B6-4261-9871-5804062DF44B) Antidote:: haemodialysis > [!key points] > - enhanced elimination haemodialysis +/- [[Decontamination#Whole bowl irrigation|WBI]] > - fluid resus 2L NaCl then 200mL/H or 2x maintenance rate > - can cause *low anion gap metabolic acidosis* Therapeutic dose is 300-2700 mg/day # Pharm - alters urinary concentrating ability → nephrogenic [[Diabetes insipidus]] - small ↓ in renal f(x) can cause a large change in lithium excretion - lithium competes with Na and K for re-absorption, ∴ hyponatremia can cause increased lithium resorption 95% excreted in urine elimination half-life 12-27 hours; longer in elderly > peak levels 2-4 hours for non-sstained release preparations > 6-8 hours for slow-release preparations # risk assessment - hypovolaemia/dehydration -- stops lithium from being excreted - [[hyponatremia]] -- kidneys will re-absorb lithium thinking it is sodium - [[hypokalemia]] - low urine osmolality compared ot serum osmoality suggests [[Diabetes insipidus]] - dose - renal failure - ACE-i - thiazide diuretics - NSAIDs > Low anion gap metabolic acidosis on VBG (can be from lithium tox or multiple myeloma) Peak levels >5 mmol/L occurring 4–8 hours post ingestion are not unusual following acute overdose. **ECG:** - T flattening or inversion often on therapeutic lithium treatment - PR, QRS, and QT intervals correlate with toxic lithium levels - fatal cardiac events are unusual # Acute lithium poisoning ## \> 25g  - moderate-severe GI features(nausea, vomiting, abdo pain, nausea) - neuro toxicity is rare (below; often delayed.  tremor is earliest sign; rarely progress if renal function OK)  - ataxia - confusion - somnolence - myoclonus - seizures - coma significant fluid losses may occur  also [[hyponatremia]] ## <25g - minor GI symptoms (nausea, vomiting, abdo pain, diarrhoea) - neuro features rare; possibly hyerreflexia and tremor # Chronic lithium toxicity [[Long QT]] level >2.5 noteworthy Grade 1 (mild) - tremor, hyperreflexia, agitation, muscle wakness, ataxia Grade 2 (moderate) - stupor, rigidity, hypertonia, hypotension Grade 3 (severe) - coma, seizures, myoclonus * gastro symptoms are NOT prominant with chronic toxicity can cause [[thyrotoxicosis]] # treatment - IVF - aim levels <2.5 - +/- [[haemodialysis|dialysis]] if neuro sx, Persistently ↑ or rising serum concentration > 5, or lithium > 4 and egfr <45 - all chronic overdoses need admission; neuro tox dangerous - Likely d/c when level <1.5 and down-trending; need it <1 by 48 hours - Serial lithium levels Q 4-6 hours often dialysis if lithium level >3.5 mmol/L in chronic tox GIT decontamination (whole bowel irrigation) - indicated if > 40 mg/kg ingested - PEG - gastric lavage w/ large bore OGT i intubated # Related Questions ## lithium toxicity - [ ] 20Q: [Mania and Lithium Toxicity](x-devonthink-item://93BDB055-D606-4878-9FA5-0BEFF977FEF7?page=13) -- [Answer](x-devonthink-item://736EC9CD-AC9C-4588-BA1E-F4AD190CBA47?page=6) - [ ] 21Q: [Lithium toxicity](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=12) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=16)