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Lithium Toxicity Management (EXTRIP Guidelines)

Lithium Toxicity Management (EXTRIP Guidelines): Suspected lithium toxicity → Recognise toxicity: clinical features matter more than the level → Identif...

Pathway Overview

14 steps

Algorithm Steps

14 total

  1. 01Start

    Suspected lithium toxicity

    Adult taking lithium, or lithium overdose, with symptoms or lithium >1.5 mmol/L. Child: call the Poisons Information Centre (13 11 26) or a clinical toxicologist. Pregnant: involve obstetrics early; near term, alert the neonatal team (lithium crosses the placenta).

  2. 02Action

    Recognise toxicity: clinical features matter more than the level

    Features progress from mild to severe. The level correlates poorly with brain toxicity, especially in chronic toxicity.

    • Early: tremor, nausea, vomiting, diarrhoea, drowsiness, ataxia, hyperreflexia, weakness
    • Severe: confusion, rigidity, myoclonus, seizures, coma, hypotension
    • ECG: bradycardia, sinus node dysfunction, T-wave inversion, QT prolongation
    • Chronic toxicity: neurological signs dominate; can occur at only slightly raised levels
    • Exclude NMS, serotonin syndrome, sepsis, hypercalcaemia and co-ingestants
  3. 03Action

    Identify the pattern: acute, chronic or acute-on-chronic

    The pattern changes the risk and whether decontamination applies.

    • Acute: overdose, not on lithium before; GI symptoms early; neurotoxicity can be delayed
    • Chronic: accumulation on therapy (dehydration, AKI, NSAIDs, ACE inhibitors, ARBs, thiazides)
    • Acute-on-chronic: overdose in a patient on regular lithium
    • Sustained-release overdose: absorption and peak level can be delayed
  4. 04Action

    Investigations: lithium level, kidney function, sodium

    Repeat lithium every 2-4 h at first, then every 6-12 h once it falls.

    • Lithium: never in a lithium heparin tube (false high result); use the tube your lab specifies
    • Record the time of the last dose or ingestion; read the level with the history and clinical state (after acute ingestion the level can be high before brain toxicity develops)
    • UEC: creatinine, eGFR, sodium, potassium; measure urine output
    • Calcium, glucose, TSH (chronic therapy); ECG
    • Deliberate self-poisoning: paracetamol level
  5. 05Warning

    STOP lithium and drugs that raise the lithium level

    Do not give further lithium while toxic.

    • Stop lithium
    • Stop NSAIDs, ACE inhibitors, ARBs, thiazides and other diuretics
    • Review drugs that add neurotoxicity or prolong the QT
  6. 06Action

    Decreased consciousness, seizures or dysrhythmia: resuscitate, ICU, dialysis now

    These features meet EXTRIP criteria for dialysis at any lithium level. Call ICU and nephrology now.

    • ABCDE; protect the airway if consciousness is reduced
    • Seizures: benzodiazepine first line
    • ICU also if lithium >4.0 mmol/L, hyperthermia or kidney failure
    • No dialysis on site: call retrieval and transfer early
  7. 07Warning

    Before IV fluid: check sodium, urine output and heart failure

    Lithium can cause nephrogenic diabetes insipidus (NDI): large volumes of dilute urine.

    • NDI: 0.9% sodium chloride can cause hypernatraemia; check sodium with each lithium level
    • Sodium rising: change to hypotonic fluid with specialist advice; lower chronic hypernatraemia slowly (about 10 mmol/L per 24 h)
    • Heart failure, oliguria or anuria: fluid will not clear lithium and can overload; discuss dialysis early
  8. 08Action

    IV fluid to restore normal volume (euvolaemia)

    Volume depleted: IV 0.9% sodium chloride. Aim for normal volume and good urine output.

    • Do not give forced diuresis: it worsens fluid and sodium problems
    • Record fluid balance and urine output
    • Check sodium and creatinine with each lithium level
  9. 09Action

    Acute or acute-on-chronic overdose only: gut decontamination

    Activated charcoal does not bind lithium. Get toxicology advice (Poisons Information Centre 13 11 26).

    • Activated charcoal: only for a toxic co-ingestant
    • Sustained-release overdose: consider whole bowel irrigation (PEG solution) within 12 h
    • Whole bowel irrigation only if alert, airway safe, no ileus or obstruction, and haemodynamically stable; watch potassium (hypokalaemia)
    • Sodium polystyrene sulfonate: no proven benefit; do not use routinely
  10. 10Decision

    EXTRIP criteria for dialysis met?

    Any one is enough: impaired kidney function with lithium >4.0 mmol/L; decreased consciousness, seizures or life-threatening dysrhythmia at any level; lithium >5.0 mmol/L; significant confusion; or expected time to lithium <1.0 mmol/L over 36 h.

    • Recommended (EXTRIP 1D): impaired kidney function and lithium >4.0 mmol/L
    • Recommended (EXTRIP 1D): decreased consciousness, seizures or life-threatening dysrhythmia, at any level
    • Suggested (EXTRIP 2D): lithium >5.0 mmol/L, significant confusion, or expected time to <1.0 mmol/L over 36 h
    • Impaired kidney function: eGFR <45, AKI stage 2-3, or (no baseline) creatinine 176 µmol/L or more (132 µmol/L if elderly or low muscle mass)
  11. If Yes
    1. 11Action

      Criteria met: intermittent haemodialysis

      Call nephrology now. No dialysis on site: arrange retrieval without delay.

      • Intermittent haemodialysis preferred; CRRT if haemodialysis is not available
      • Stop when lithium <1.0 mmol/L or clear clinical improvement; at least 6 h if levels are not available
      • After dialysis: serial lithium levels over 12 h; rebound can need more sessions
      • Keep the dialysis catheter until no more sessions are expected
    2. 12Action

      Monitor until recovered

      Clinical recovery often lags behind the fall in lithium.

      • Serial neurological examination
      • Lithium, sodium, creatinine and urine output: every 6-12 h once lithium is falling
      • Medically fit: clinically improved and lithium <1.5 mmol/L for 1-2 days; a large sustained-release overdose can need 3-4 days of observation
      • Persistent cerebellar or cognitive signs: consider SILENT; arrange neurology follow-up
    3. 13Outcome

      Recovery and follow-up

      Deliberate overdose: mental health assessment before discharge. Decide about restarting lithium with psychiatry and the patient.

      • Restart lithium only by team decision, after levels are in or below range for at least 24 h
      • Stop interacting drugs; teach when to withhold lithium and seek advice (vomiting, diarrhoea, poor intake)
      • Pregnant or planning pregnancy: perinatal psychiatry advice before choosing a mood stabiliser
      • Check kidney function, thyroid function and calcium at follow-up
    If No
    1. 14Action

      Criteria not met: supportive care and reassess

      Re-check the dialysis criteria with each level and with any change in mental state.

      • Admit if symptomatic, or on chronic therapy with lithium >2.0 mmol/L
      • Lithium level every 2-4 h until it clearly falls
      • Estimate the time to reach <1.0 mmol/L; more than 36 h meets the dialysis criteria
      • Acute or sustained-release overdose: observe even if well; the level can rise late, so one normal level is not enough
    2. Path rejoins step 12Shared downstream outcome

Guideline Source

EXTRIP recommendations for extracorporeal treatment in lithium poisoning (Decker et al, Clin J Am Soc Nephrol 2015)

DOI: 10.2215/CJN.10021014View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • The lithium level correlates poorly with brain toxicity, especially in chronic toxicity: treat the patient, not only the number.
  • EXTRIP dialysis criteria rest on very low-quality evidence (case reports); discuss borderline cases with a clinical toxicologist and nephrologist.
  • Lithium rebound after dialysis can need repeat sessions.
  • Neurological sequelae (SILENT) can persist despite treatment.
  • Management in children is not covered; seek clinical toxicology advice.

Contraindicated Populations

Children: seek clinical toxicology advice (Poisons Information Centre 13 11 26)

Applicable Regions

AUUSEUGlobal

AU: Poisons Information Centre 13 11 26 (24 h). Australian labs report lithium in mmol/L (1 mmol/L = 1 mEq/L).

US: Poison Control 1-800-222-1222. Some US labs report lithium in mEq/L (same numbers as mmol/L).

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Lithium Toxicity Management (EXTRIP Guidelines)?

The Lithium Toxicity Management (EXTRIP Guidelines) is a emergency clinical algorithm for Psychiatry. It provides a structured decision tree to guide clinical decision-making, based on EXTRIP recommendations for extracorporeal treatment in lithium poisoning (Decker et al, Clin J Am Soc Nephrol 2015).

What guideline is the Lithium Toxicity Management (EXTRIP Guidelines) based on?

This algorithm is based on EXTRIP recommendations for extracorporeal treatment in lithium poisoning (Decker et al, Clin J Am Soc Nephrol 2015) (DOI: 10.2215/CJN.10021014).

What are the limitations of the Lithium Toxicity Management (EXTRIP Guidelines)?

Known limitations include: The lithium level correlates poorly with brain toxicity, especially in chronic toxicity: treat the patient, not only the number.; EXTRIP dialysis criteria rest on very low-quality evidence (case reports); discuss borderline cases with a clinical toxicologist and nephrologist.; Lithium rebound after dialysis can need repeat sessions.; Neurological sequelae (SILENT) can persist despite treatment.; Management in children is not covered; seek clinical toxicology advice.. Individual patient factors may require deviation from these recommendations.

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