tompat
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a 50 yr old chronic alcoholic presents with chief complains of nausea vomiting and vague abdominal pain.he has not consumed alcohol since last 24 hrs , but had some pain in his back so took OTC pain killers in moderat e dose .on physical examination there is moderate pain on palpation of abdomen.lab tests shows marked hyperbilirubinemia, AST 2090IU/L ,ALT 400IU/L, prolonged PT/INR.how wud u treat this pt.given the following options
 )party time , more alcohol
 aerosolized n-acetylcystein
 forced alkaline diuresis
 acidify the urin
 abstinence and supportive treatment.
(dont expect perfection)
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| drhouse
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aerosolized n acetylcystein
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| jean robert
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forced alkaline diuresis
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| new_n_lost
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forced alkaline diuresis If it were less than 12hrs then NAC wud have been effective.
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| drhouse
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hi NLL,
NAC can be useful to some extent till 48 hrs.
i know that paracetamol is acidic drug but, forced alkaline diuresis is not mentioned anywhere for it s treatment
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| clavicle
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n-acetylcystine is the answer.
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| tompat
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try again guys
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| mytime
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| tompat
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the ans is more alcohol
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| mytime
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So , ye si remember a pt. we had once in the ICU. Absolutely rt. I was so then! Just forgot! 
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| new_n_lost
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I m Sorry Dude but u r seriously Mistaken on the Part that In a Chronic Alcoholic Pt giving More alcohol will save the Pt from More toxic effects of Acetaminophen. That is only possible in a Acute Setting for a first timer who has an acute ingestion of Alcohol but not in a Chronic Setting.
Edited by new_n_lost on 07/07/07 - 03:36 PM
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| SILVER
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wouldn't drinking more alcohol induct the enzymes even more and cause the enzymes to metabolize the acetaminophen into more of NAPQI which is hepatotoxic??!? therefore the moderate dose of acetaminophen actually ends up becoming extremely toxic in this patient's case cuz the enzymes are forming NAPQI and glutathione is depleted which can't detox the NAPQI.
furthermore, this person has come to you in the ER with sky-rocketing hepatic enzymes indicating that liver injury has begun, so how can you be giving him MORE alcohol??!
makes more sense to alkalinize the urine and diurese the patient.
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| new_n_lost
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Giving this person More Alcohol after a day of Abstinence wud actually enhance the Liver Injury cos the Acetaminophen is already being Metabolized in the Liver hence Giving this person Alchol is not going to help him rather induce further toxic effects of NAPQI (toxic metabolite of Acetaminophen). The Only Way to Fight NAPQI is Glutathione which is already depleted in cases of Chronic Alcoholism. Giving this person IV NAC and and having a Forced Alkaline Diuresis helps to relieve the body of Excessive H ions and leaves the bases to deal with other Toxic protons.
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| tompat
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hmm good points but ..
NAC here in the option is aerosolized which aint gonna work. now we have an induced P450 which is going to metabolize more of acetaminophen n will lead to more toxicity.if at this point we give alcohol it is going to compete with acetaminophen and hence prevent its metabolism and body will have time to get rid of acetaminophen by other ways.
well i never came across forced alkaline diuresis for acetaminophen toxicity, where is it given?please let me know
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| SILVER
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well, alkaline diuresis is the overall treatment of free radicals, and more specifically meant for salicylates. out of the choices you gave, it was the most reasonable one, even though acetaminophen is not a salicylate.
alkalanization of urine is given in the Emergency Medicine Companion Handbook by the American College Of Emergency Physicians Handbook Pg 546.
most books also mention that regardless of the time elapsed NAC should be given, particularly intravenous (aerosolized has no effect) and activated charcoal also plays an important role (but only within the first hour post-ingestion).
"Despite the lack of randomized controlled trials, we believe that one should err on the side of treatment with acetylcysteine. If there is uncertainty regarding the dose or time of ingestion, a full 72-hour regimen, regardless of acetaminophen or transaminase levels, is prudent." (Postgraduate Medicine Online).
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| tompat
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i agree ur quote from postgraduate medicine online. nac has to be iv or oral,any time , so its not the option here cause here its aerosolized.again even thou alkalanizing urine will decrease free radicals but who will take care of induced P450 producing benzoquinoimines.
the take home point is alcohol competes with acetaminophen for P450, its given in the same article u read on postgraduate online!
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| SILVER
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i think you need to read that article carefully. it says that alcohol competes with acetaminophen in ACUTE alcohol ingestion. your patient tompat is a CHRONIC alcoholic in whom the induction of CYP2E1 and glutathione depletion is the cause for accumalation of NAPQI and acetaminophen toxicity. at this point, alcohol no longer competes with acetaminophen.
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| new_n_lost
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tompat wrote:
i agree ur quote from postgraduate medicine online. nac has to be iv or oral,any time , so its not the option here cause here its aerosolized.again even thou alkalanizing urine will decrease free radicals but who will take care of induced P450 producing benzoquinoimines.
the take home point is alcohol competes with acetaminophen for P450, its given in the same article u read on postgraduate online!
Dude The Take Home Point is Not that There is Competitve Antagonism here bw Acetaminophen and Alcohol for CYP2E1. Alcohol DOES NOT COMPETE With Acetaminophen if that were the Case then the Antidote for the Acetaminophen Toxicity wud have been Alcohol. The Point That SHUD be Taken Home Is that In Chronic Alcoholics the Normal Dosage of Acetaminophen Can cause Massive Hepatotoxicity as the 2nd Pathway for Acetaminophen is Already in Increased Numbers. Thus leading to the oxidation of APAP to NAPQI faster than normal.
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| new_n_lost
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silver wrote:
well, alkaline diuresis is the overall treatment of free radicals, and more specifically meant for salicylates. out of the choices you gave, it was the most reasonable one, even though acetaminophen is not a salicylate.
alkalanization of urine is given in the Emergency Medicine Companion Handbook by the American College Of Emergency Physicians Handbook Pg 546.
And Harrison's , Oxford Textbooks.
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| tompat
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agree with u. but given the choices alcohol is the right one, who the heck will give alcohol instead of giving iv nac
Edited by new_n_lost on 07/07/07 - 08:53 PM. Reason: Used a better word.
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| tompat
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to silver,
yes i have read it carefully, it says alcohol wont be there to compete with acetaminophen after a brief abstinence.leaving P450 induced.
but we are talking about what happens if we now give him alcohol?that is what if we treat him with alcohol?
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| new_n_lost
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Ok One Question y do we really NAC i mean wht the Mechanism of NAC ??
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| tompat
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to replenish glutathion , which wud then combine with the toxic product of acetaminophen metabolism to form a non toxic product
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| SILVER
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NAC is a precursor of glutathione
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| SILVER
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and NAC increases glutathione availability to bind to NAPQI.
In addition, NAC increases local nitric oxide concentrations, and this vasodilatory effect on microcirculatory blood flow enhances local oxygen delivery to peripheral tissues. These vasodilating effects decrease morbidity and mortality even in the setting of established hepatotoxicity.
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