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Morbidity & Mortality Review

Morbidity & Mortality Review. Cindi Hurley October 11, 2007. Case Presentation. CC: Tylenol Overdose HPI: 33 year old Indian Female found somnolent by friends ingested 7 ER Tylenol PM to help her sleep denied suicide attempt. Physical Exam.

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Morbidity & Mortality Review

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  1. Morbidity & Mortality Review Cindi Hurley October 11, 2007

  2. Case Presentation • CC: Tylenol Overdose • HPI: 33 year old Indian Female found somnolent by friends ingested 7 ER Tylenol PM to help her sleep denied suicide attempt

  3. Physical Exam VS: BP 104/67; HR 111; RR 18; T 98; Sat 97% Gen: A&Ox3, responds but somnolent HEENT: EOMI, PERRLA, MM dry & pale Neck: Supple, no LAD, no JVD Chest: CTAB CV: Reg Rhythm, Tachy, no m/r/g

  4. Physical Exam, cont’d Abd: S/NT/ND, + BS, Hepatic Border 2 cm < costal margin, no TTP MSK: Full ROM Neuro: CN 2-12 Intact with no focal deficits Psych: Depressed Mood with 5/8 SIGECAPS

  5. Labs CBC: WBC 9.1, Hgb 11.8, Hct 36.1, Plt 18,000 Chem: Na 134, K 3.9, Cl 95, HCO3 8.8, BUN 8, Cr 1.3, Glc 296*, AG 34, Alb 3.5, Bili 1.1, AST 201, ALT 207, APhos 84 ABG: pH 7.05, pCO2 20.8, pO2 135, BE –23 Coags: INR 1.25, PT 13, PTT 29 Tox: Acetaminophen 211, All others neg

  6. Acetaminophen (APAP) Review • Available as 325 or 500 mg, 650 mg ER • Tylenol PM = 500 mg APAP & 25 mg Diphenhydramine, take 2 tabs • Most widely used analgesic and anti-pyretic in US and world • Contained in > 100 products

  7. APAP Review, cont’d • Max: 1000 mg/dose or 4000 mg/24 hrs • Toxic dose at 7000 mg but lower in susceptible pts • Most common cause of Acute Liver Failure in US (replacing viral hepatitis) • 2nd most common reason for liver transplantation

  8. APAP Metabolism • With nl dosing, 95% of APAP is conjugated with glucuronide and sulfate and excreted in urine • 2.5% is excreted unchanged in urine • 2.5% is metabolized into NAPQI – a highly toxic intermediate • NAPQI is rapidly conjugated with glutathione and excreted in urine

  9. Treatment for Overdose • Activated charcoal for pt that presents within 4 hrs of ingestion • Review Rumack-Matthews normogram to see if N-acetylcysteine (NAC, Mucomyst) is appropriate • NAC is a precursor of glutathione and combines with NAPQI

  10. Complications of Overdose • Coagulopathy (INR > 1.5) • Hypoglycemia • Renal Failure • Metabolic Acidosis • Hepatic Dysfunction  Acute Liver Failure (ALF) • Encephalopathy, Cerebral Edema and ↑ICP

  11. Back to Our Patient • See handout for lab results • Sat eve at 8:00 PM  AMS, MELD = 27 • Arranged transfer to Emory • Transplant team required pt to be intubated for transport

  12. Recommendations • If INR > 1.5, need mgmt in ICU with frequent neuro checks • For pts in a non-transplant center, early consultation with a transplant center • With APAP-related ALF, if arterial pH < 7.3 should send to transplant center • Sedatives are discouraged so that mental status can be accurately assessed

  13. Recommendations, cont’d • If stage 3/4 encephalopathy  intubation • Sedation for intubation with propofol because it may reduce cerebral blood flow • In pt not bleeding & INR < 7, not necessary to give FFP • Not necessary to give plt unless < 10,000

  14. Recommendations, cont’d • If ALF, transfer early as transportation may be dangerous with stage 3-4 encephalopathy • If ALF & MELD > 10  candidate for liver transplant

  15. Outcome • 41 day stay at Emory but no liver transplant • Prolonged encephalopathy 2/2 liver failure • Right Cartotid Injury 2/2 Swan-Ganz catheter misplacement s/p repair • Vent associated PNA 2/2 Acinetobacter • Tracheostomy 2/2 prolonged vent wean

  16. Outcome Cont’d • Right Thigh Hematoma s/p evacuation • UTI • PEG tube for nutrition • D/C to LTAC on 9/26

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