Development of Hepatic Failure Despite Use of Intravenous Acetylcysteine After a Massive Ingestion of Acetaminophen and Diphenhydramine

• Published in: Annals of emergency medicine Vol. 54; no. 3; pp. 421 - 423
• Main Authors: Schwartz, Eric A., MD, Hayes, Bryan D., PharmD, Sarmiento, Kathleen F., MD
• Format: Journal Article
• Language: English
• Published: New York, NY Mosby, Inc 01.09.2009; Elsevier
• Subjects: Acetaminophen - blood; Acetaminophen - poisoning; Acetylcysteine - administration & dosage; Alanine Transaminase - blood; Analgesics, Non-Narcotic - blood; Analgesics, Non-Narcotic - poisoning; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Antidotes - administration & dosage; Aspartate Aminotransferases - blood; Biological and medical sciences; Charcoal - administration & dosage; Diphenhydramine - poisoning; Drug Combinations; Drug intoxications. Doping; Drug Overdose - blood; Drug Overdose - drug therapy; Emergency; Fatal Outcome; Female; Free Radical Scavengers - administration & dosage; Histamine H1 Antagonists - poisoning; Humans; Intensive care medicine; Liver Failure - chemically induced; Medical sciences; Middle Aged; Pharmacology. Drug treatments; Suicide, Attempted; Thiol; Intensive care; Intravenous administration; Antimigrainous agent; Acetylcysteine; Hepatic disease; Diphenhydramine; Antihistaminic; Ingestion; Mucolytic; Liver failure; Paracetamol; Analgesic; Antipyretic; Digestive diseases; Antagonist; H1 Histamine receptor; Antiemetic; Resuscitation
• ISSN: 0196-0644; 1097-6760
• DOI: 10.1016/j.annemergmed.2008.10.001

Acetylcysteine is an antidote used to prevent liver failure after acetaminophen overdose. We report the development of liver failure despite administration of intravenous acetylcysteine in a patient with massive ingestion of an acetaminophen and diphenhydramine combination product. An atypical, delayed, bimodal peak in the serum acetaminophen concentration was observed. This case suggests that individualized dosing of antidotal therapy may be needed for preparations of acetaminophen that result in delayed absorption or after massive overdose.