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Morbidity Mortality Review

Case Presentation. CC: Tylenol OverdoseHPI: 33 year old Indian Female found somnolent by friends ingested 7 ER Tylenol PM to help her sleep denied suicide attempt. Physical Exam. VS: BP 104/67; HR 111; RR 18; T 98; Sat 97%Gen: A

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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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