100,000 mg Tylenol OD

[firefighter523]

Had an overdose of Tylenol the other day, a pt took two-hundred, 500 mg (extra strength) at 10 am. We got the call about 3pm. Arrive on location to find a 52 yom, standing in front of the sink vomiting pink stuff. Don't know what the pink stuff was, either the red caplets or blood. 15 min transport time running hot to hospital. BP: 168/82, NSR 89 w/out ectopy, R: 12 non-labored, clear lungs all around, amazingly, his belly was not tender, or upset, SPO 98 on 4lpm NC. 18 ga in left hand KVO. Wanted to give 1gm/kg charcoal, was denied with a 7 min ETA at this point. (Kinda figured that)

What I was wondering was, what do you think was happening to his liver and kidneys at this point, pt was not jaundice BTW.

[tniuqs]

Question would be the time frame from ingestion, to nausea....good old natures way.

Tylenol has a nasty habit of prolonging peak onset for up to 24 hours, somethimes longer.

Really rough on the liver and kidneys as well.

I suspect that the hospital initiated N-acetylcysteine (Mucomist)?

cheers

[AZCEP]

Yep, they will use the Mucomyst, and as long as the LFT's don't remain elevated he will actually do okay.

The pink vomitus was probably from the esophageal lining. Early charcoal would have done a good job of binding the APAP that was in the GI tract, but it also binds the Mucomyst.

[Ridryder 911]

Actually, Mucumyst is only really helpful if initiated in the early onset usually within 6hours.. that is why I am a big proponent of carrying on EMS rigs in nebulizer form, although it does stink like sulphur.

I had read at one time administration of mucumyst in the initial first hours reduces the acetaminophen level, quite a bit. The usual treatment for overdose is to monitor the level, and if very toxic dialysis therapy may be initiated.

R/r 911

[AZCEP]

The way our pharmacist described it, the oral dosing of Mucomyst works better for Tylenol ingestions, than the nebulized route. Could be that was his experience, but I'd be in favor of either over neither with the number of APAP overdoses we see.

Particularly with the uproar we cause by using charcoal for the same patient. Doctors just don't like having to double/triple the dose of the Mucomyst because we used it.

I'll pick something else to argue about.

[becksdad]

My understanding of acetaminophen OD, is that it is reversible if N-acetylcystiene if therapy is initiated within 6 hours post-ingestion. I recently had a Doc tell me that the standard is now 8 hours. Sounds like your patient just made the window. Although I'm sure that this therapy would have been initiated no matter how long its been.

I actually did some basic research on this topic a few years ago, and I know that this substance depletes the liver of something (I can't remember what), and leads invariably to fulminant liver failure if untreated. I believe single doses of 10 grams are toxic, sometimes fatal, especially in patients with existing liver disease and/or alcoholism. Also, I think doses of 15-20 grams are universally fatal if not treated (please correct me if I'm wrong). My question - would existing therapies be effective for such a massive OD of 100 grams? Does dosage make a difference in outcomes if treated early? Also, I don't remember dialysis as part of treatment (although my memory is always subject to question)-is this utilized, and how effective is it with patients where Mucomyst is not sufficient? Thanks for any info...

[Just Plain Ruff]

lots and lots of articles can be found here:

http://scholar.google.com/scholar?q=tyleno...UTF-8&hl=en

I have found that Google Scholar gives quite good information.

[becksdad]

Thank you, Ruffems

[AZCEP]

I had a teenager take 50 mg/kg a few years ago. We didn't get notified until 14 hours after the fact, and following the N-AC treatment she did okay.

Probably due to having a previously undamaged liver, though.

[courageheartx]

correct me if im wrong. pink sputum is from heart failure or a sign the hearts going to fail. no ?yes?