Comments on: Development of Hepatic Failure Despite Use of Intravenous Acetylcysteine After a Massive Ingestion of Acetaminophen and Diphenhydramine http://www.thepoisonreview.com/2009/10/27/development-of-hepatic-failure-despite-use-of-intravenous-acetylcysteine-after-a-massive-ingestion-of-acetaminophen-and-diphenhydramine/ "Poison is everything and no thing is without poison" - Paracelsus Sat, 28 Jan 2012 22:47:06 +0000 hourly 1 http://wordpress.org/?v=3.3.1 By: Leon http://www.thepoisonreview.com/2009/10/27/development-of-hepatic-failure-despite-use-of-intravenous-acetylcysteine-after-a-massive-ingestion-of-acetaminophen-and-diphenhydramine/comment-page-1/#comment-10 Leon Thu, 29 Oct 2009 22:33:59 +0000 http://www.thepoisonreview.com/?p=315#comment-10 I agree that something other than pure acetaminophen toxicity was happening -- in fact, the authors of the paper suggest as much without really clarifying the issue. At 32 hours after presentation, the patient was intubated because of a Glasgow coma scale of 3, yet ALT and AST were each below 1000 -- a clinical picture not consistent with hepatic encephalopathy. Could the patient's unfortunate outcome been due to anticholinergic encephalopathy and aspiration pneumonia? I agree that something other than pure acetaminophen toxicity was happening — in fact, the authors of the paper suggest as much without really clarifying the issue.

At 32 hours after presentation, the patient was intubated because of a Glasgow coma scale of 3, yet ALT and AST were each below 1000 — a clinical picture not consistent with hepatic encephalopathy. Could the patient’s unfortunate outcome been due to anticholinergic encephalopathy and aspiration pneumonia?

]]> By: precordialthump http://www.thepoisonreview.com/2009/10/27/development-of-hepatic-failure-despite-use-of-intravenous-acetylcysteine-after-a-massive-ingestion-of-acetaminophen-and-diphenhydramine/comment-page-1/#comment-9 precordialthump Thu, 29 Oct 2009 05:34:37 +0000 http://www.thepoisonreview.com/?p=315#comment-9 That's really interesting and somewhat puzzling case. I can't help but think something else was going on... coingestants, sepsis? What caused the broad complex tachycardia (treated with NaHCO3)? I got the impression that the INR and LFTs improved without factor replacement and that progressive APAP-induced hepatic failure wasn't the key issue. Could the medical examiner's assessment be complicated by the fact that there was withdrawal of treatment and presumably significant hypoxemic multi-organ effects following this? Finally, great tip about the serial APAP levels in the context of an anticholinergic-induced ileus. That’s really interesting and somewhat puzzling case.

I can’t help but think something else was going on… coingestants, sepsis? What caused the broad complex tachycardia (treated with NaHCO3)? I got the impression that the INR and LFTs improved without factor replacement and that progressive APAP-induced hepatic failure wasn’t the key issue.

Could the medical examiner’s assessment be complicated by the fact that there was withdrawal of treatment and presumably significant hypoxemic multi-organ effects following this?

Finally, great tip about the serial APAP levels in the context of an anticholinergic-induced ileus.

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