Potentially fatal paracetamol overdose and successful treatment with 3 days of intravenous N-acetylcysteine regime - A case report

Abstract

Introduction: Paracetamol overdose is the most common drug overdose worldwide. To our knowledge, the maximum number of paracetamol tablets ingested reported in the literature is 45 g. Clinical Picture: We describe a 21-year-old patient who acutely ingested 120 tablets, each 500 mg paracetamol (i.e., 60 g equivalent to 1200 mg/kg body weight) in a suicidal attempt. Our patient also drank 2 bottles of codeine-based cough syrup equivalent to 360 mg of codeine. At 6 hours post ingestion, her serum paracetamol level was 207 mg/L. The poor prognostic factors for paracetamol overdose in our patient included massive paracetamol ingestion (confirmed by blood levels), codeine co-ingestion and elevated serum amylase (189 U/L). Treatment: She was treated with a 3-day modified regimen of intravenous N-acetylcysteine. Outcome: The liver function tests and the prothrombin time remained normal over the second and third day of admission and the patient was discharged without complications on the fifth day. Conclusion: From this experience we feel that in very severe paracetamol poisoning, a modified regime of intravenous N-acetylcysteine for 3 days is safe and efficacious.