442 CASE FI LES: CTITICALCARE

ANSWERS TO CASE 37:

Sr,tmmary: This patient is a 46-year-o1d man with lethargy and abdominal pain,
found to have elevated liver transaminase enzymes in the setting of significant acet-
aminophen ingestion. His presentation to the emergency department is consistent
with hepatotoxicity secondary to acetarninophen overdose.
. Likely cause of current condition: Acetaminophen overdose.
r Next step in managemenfi Gastric lavage following massive ingestions may be
effective in retrieving undigested pills or pill fragments 30 to 60 minutes after
the ingestion. Activated charcoal that absorbs most toxins (due to its large
surface area) should only be administered to awake patients or to comatose
patients after appropriate airway protection. The dose is 1 S/kg orally or via
gastric tube, with the goal of a 10:1 (charcoal:toxin) ratio.
o Disease stages: There are 4 distinct stages of acetaminophen-induced hepato-
toxicity: (1) preclinical toxic e#ects (no lab abnormalities); (2) hepatic injury
(elevated transaminase enzyrnes); (3) hepatic failure; and (4) recovery. Each
stage has a different prognosis and management strategy. This patient would
appear to be stage 2 based on his initial evaluations.

ANALYSIS
Objectives

1. To learn the clinical manifestations, management, and outcome of acetamino-

phen, salicylate, tricyclic antidepressants, alcohol, oral hypoglycemics, cya-
nide, and propofol.
7. To learn when activate charcoal is indicated in the management of substance
ingestion/overdose.

3. To recognize the importance of airway, breathing, and circulation managernent

in patients with substance ingestion/overdose.

Cansiderations
This 46-year-o1d patient was given a prescription for acetaminophen/hydrocodone
(Vicodin) and was supplementing this medication with extra-strength acetamino-
phen to treat his hack pain. The additional over-the-counter acetaminophen is suf-
ficient to exceed the liver's ability to metabolize acetaminophen safely. Significant
hepatic injury is evident by the patient's elevated transarninase enzymes. Due to the
potential for decreased CI motility from opiates, such as hydrocodone, the acet-
aminophen toxicity could be potentiated because the compound remain in
"vould
the patientts s]rstem over a protronged period of time"