Cesar Davila-Chapa, MD
Resident Physician
LSU Health Shreveport
Shreveport, Louisiana
Disclosure information not submitted.
Nasim Motayar, MD
Assistant Professor of Clinical Medicine
Louisiana State University Health Sciences Center
Shreveport, Louisiana
Disclosure information not submitted.
Rajkamal Hansra, MD
Doctor
Louisiana State University Health Sciences Center
Shreveport, Louisiana, United States
Disclosure information not submitted.
Title: Massive Acetaminophen Poisoning: Avoiding a Fatal Outcome
Case Report Body:
Introduction:
Acetaminophen (APAP) is one of the most consumed over the counter medications but can have fatal outcomes when taken in toxic dosages. We present a case of a 76-year-old male admitted to the MICU for APAP poisoning.
Description:
A 76-year-old male with a history of Alcohol abuse presents to the ED via EMS 30 minutes after an ingestion of 200 APAP pills. Given the timing of ingestion to arrival the patient was given 50g of activated charcoal. Initial APAP level were 410 mg/L. A loading dose of N-Acetylcysteine (NAC) was given, and the patient was admitted to the ICU. NAC was continued at 100 mg/kg/hr with APAP levels rising to >600 mg/L. The patient became unresponsive, hypotensive, and tachypneic. An ABG revealed severe metabolic acidosis. The patient was immediately intubated for airway protection and started on a bicarbonate, norepinephrine, and vasopressin drip. Patient’s APAP levels continued to be >600 mg/L despite 10 hours of NAC, so the decision was made to undergo a 4-hour session of hemodialysis (HD). Subsequent APAP level decreased to 136 mg/L with resolution of metabolic abnormalities. During HD NAC infusion rate was doubled. NAC was continued for 36 hours at which time the APAP level fell below the level of toxicity. Throughout the patient’s stay serum liver AST increased to 65, ALT up to 91. Synthetic liver functions including PT, INR, and bilirubin levels remained stable. The patient’s acute encephalopathy resolved on day 2 of ICU stay and subsequently extubated.
Discussion:
The complication of APAP poisoning is acute liver failure. APAP overdoses in the United States account for 50,000 visits to the ED, 10,000 hospitalizations, and 500 deaths annually. While it is known that supportive care and the administration of NAC is the standard of care for APAP toxicity, The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup recommends HD in patients with APAP poisoning who present with altered mental status and severe metabolic acidosis with APAP levels of >1000 mg/L if NAC has not been administered, signs of mitochondrial dysfunction and an APAP level >700 mg/L if NAC is not administered, or signs of mitochondrial dysfunction and an APAP level >900 mg/L if NAC is administered. Expedited use of activated charcoal, NAC, and HD as per EXTRIP consensus guidelines were effective in our case.