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Clinical Atlas Prestige · Evidence-first

Psych VivasEmergency psychiatry

Psych Vivas · Emergency psychiatry

Lithium toxicity — structured clinical viva

Fellowship viva on lithium toxicity patterns, interactions, EXTRIP criteria, decontamination myths, rebound, and restart.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar. ED calls about a 70-year-old woman on lithium for bipolar disorder with coarse tremor, ataxia and drowsiness. New medications: naproxen and indapamide. Lithium 3.1 mmol/L, creatinine doubled from baseline. Junior doctor asks whether to give activated charcoal, start forced diuresis with frusemide, and wait until the level exceeds 5 before calling nephrology. Cross-examine the candidate on pattern, mechanisms, EXTRIP, SILENT, and prevention.

Interpretation

Reveal interpretation

Reject the junior plan. Activated charcoal does not bind lithium. Forced loop-diuretic diuresis is not the primary detox strategy. Waiting for Li greater than 5 before nephrology is unsafe: EXTRIP recommends ECTR for decreased consciousness at any lithium level and for impaired kidney function with Li greater than 4.0; it suggests ECTR for significant confusion and when expected time to Li less than 1.0 exceeds 36 hours. This patient is drowsy with AKI and Li 3.1 — call nephrology/toxicology now.[1][2]

Pattern. Chronic / acute-on-chronic toxicity precipitated by NSAID (naproxen) and thiazide-like diuretic (indapamide) plus age-related clearance risk. Neuro-dominant phenotype; severity can outrun the numerical band expected from acute naive overdose.[5][3]

Immediate care. Stop lithium, stop naproxen and indapamide, ABC support, ECG monitoring, serial levels, U&E, isotonic saline for volume repletion, early ECTR decision with HD preferred if indicated, plan for rebound checks.[1][2]

SILENT. Warn that severe neurotoxicity can leave persistent cerebellar/extrapyramidal deficits after levels normalise — motivates aggressive timely care.[4]

Aftercare. Fix interaction pathway; monitoring education; nuanced restart weighing anti-suicide benefit after recovery.[6][3]

Escalating viva probes

  1. Why does thiazide raise lithium? Volume depletion → increased proximal Na reabsorption → lithium follows.
  2. Name EXTRIP recommended criteria verbatim.
  3. What is rebound and when do you recheck?
  4. Define SILENT.
  5. Would you ever restart lithium? When, with what safeguards?
[1] [3] [4] [6]

Key points

Charcoal myth

Activated charcoal does not bind lithium.

EXTRIP

Recommend ECTR for impaired kidneys + Li >4.0, or low consciousness/seizures/life-threatening dysrhythmia at any level.

Pattern

Chronic toxicity can be severe at modest-appearing levels.
[1] [2] [5]

References

  1. [1]Decker BS, Goldfarb DS, Dargan PI, et al. Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup Clin J Am Soc Nephrol, 2015.PMID 25583292
  2. [2]Waring WS Management of lithium toxicity Toxicol Rev, 2006.PMID 17288494
  3. [3]Finley PR Drug Interactions with Lithium: An Update Clin Pharmacokinet, 2016.PMID 26936045
  4. [4]Adityanjee, Munshi KR, Thampy A The syndrome of irreversible lithium-effectuated neurotoxicity Clin Neuropharmacol, 2005.PMID 15714160
  5. [5]Waring WS, Laing WJ, Good AM, et al. Pattern of lithium exposure predicts poisoning severity: evaluation of referrals to a regional poisons unit QJM, 2007.PMID 17412747
  6. [6]Cipriani A, Hawton K, Stockton S, et al. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis BMJ, 2013.PMID 23814104