![]() Our patient had likely overdosed the night prior given he arrived in multiorgan failure with irreversible damage to the liver. Patients lacking glutathione reserves such as those with chronic alcohol use are especially at risk, but prompt acetylcysteine administration can effectively prevent acute liver failure. CRRT is also suggested in severe cases in which patients display neurological, respiratory, or circulatory malfunctioning (encephalopathy or coma) as our patient did. Hemodialysis is recommended for patients with extreme plasma acetaminophen concentrations (> 200 µg/mL plasma at four hours post-ingestion) or displaying symptoms of mitochondrial dysfunction such as elevated lactate levels and acidosis. Recent studies show that IV NAC treatment administered at lower doses reduces potential side effects such as nausea and allergy. ![]() The patient had an elevated troponin of 35 ng/mL, but cardiac echocardiogram revealed a normal left ventricular ejection fraction of 55% (Tables (Tables1 1- -4 4).Īcetaminophen nomogram adapted from Rumack BH, Matthew H: Pediatrics 55:871, 1975 Arterial blood gas revealed a pH of 6.88, CO 2 of 51 mmHg, pO 2 of 259 mmHg. The patient had an anion gap metabolic acidosis with bicarbonate of 11 mmol/L, and evidence of acute kidney injury (AKI), with serum creatinine 7 mg/dL and creatine protein kinase >1000 units/L. Hepatic panel showed transaminitis with aspartate aminotransferase 1256 units/L (normal range 10-37) and alanine aminotransferase 232 units/L (normal range 12-78). Laboratory analysis was remarkable for a white blood cell count of 33 x 103/mm 3 with neutrophilic predominance. Upon arrival at the ED, the patient was started on vasopressors and intubated. In the ED, the temperature was 89.9 0F, with a mean arterial pressure of 50 mmHg on norepinephrine infusion, a pulse between 90 and 100 beats per minute, a respiratory rate of 20 (ventilator rate), and oxygen saturation of 94% on 100% FiO2. He had agonal breathing and pupils that were 3 mm, round, and sluggish bilaterally. Return of spontaneous circulation (ROSC) was achieved within 10 minutes of cardiopulmonary resuscitation. He received naloxone en route by the paramedics. He was in cardiac arrest with pulseless electrical activity (PEA). ![]() The patient was found by emergency medical services (EMS) with multiple bottles of empty acetaminophen around him on the bathroom floor and self-inflicted wounds on his wrist suggestive of a possible suicide attempt. A 53-year-old male with unknown past medical history was brought in via ambulance after his neighbor called due to the patient being unresponsive. ![]()
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