Hydrocodone/APAP Overdose

[wreagle96]

Patient stated they took 70 hydrocodone/APAP 10/500's.
4 hours post ingestion, serum apap = 105ug/ml, resp rate 20, A/O x 3, ast24/alt18.
8 hours, APAP decreased to 63, pt still stable.
24 hours, pt still stable, ast36/alt36, APAP levels not obtained
36 hours, RR falls to 4bpm, given naloxone, stabilizes
42 hours, ast269/alt290
44 hours APAP back up to 103
NAC initiated

any thoughts on MOA of delayed absorption? 36 hours from ingestion until resp depression. and apap began elevated, fell, then increased again ...... thoughts?

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[RustedFox]

My first thought is: what ELSE did they take that could affect absorption ?

 

[EMquest3]

Patient stated they took 70 hydrocodone/APAP 10/500's.
4 hours post ingestion, serum apap = 105ug/ml, resp rate 20, A/O x 3, ast24/alt18.
8 hours, APAP decreased to 63, pt still stable.
24 hours, pt still stable, ast36/alt36, APAP levels not obtained
36 hours, RR falls to 4bpm, given naloxone, stabilizes
42 hours, ast269/alt290
44 hours APAP back up to 103
NAC initiated

any thoughts on MOA of delayed absorption? 36 hours from ingestion until resp depression. and apap began elevated, fell, then increased again ...... thoughts?

Could the pills have clumped up to form something like a bezoar that was initially very hard to digest then after a while it broke up and caused the 36 hour spike?

 

[Apollyon]

Patient stated they took 70 hydrocodone/APAP 10/500's.
4 hours post ingestion, serum apap = 105ug/ml, resp rate 20, A/O x 3, ast24/alt18.
8 hours, APAP decreased to 63, pt still stable.
24 hours, pt still stable, ast36/alt36, APAP levels not obtained
36 hours, RR falls to 4bpm, given naloxone, stabilizes
42 hours, ast269/alt290
44 hours APAP back up to 103
NAC initiated

any thoughts on MOA of delayed absorption? 36 hours from ingestion until resp depression. and apap began elevated, fell, then increased again ...... thoughts?

At almost 2 days out, without the NAC in, I am wondering if the liver damage was past the window (the enzymes checked look like they're in the "honeymoon" phase). Hopefully some of our tox guys will check in.

 

[gro2001]

Could the pills have clumped up to form something like a bezoar that was initially very hard to digest then after a while it broke up and caused the 36 hour spike?

Not a toxicologist, but possibilities seem to be what people have said/implied:

1) Lied/wrong about time of ingestion.
2) Coningestants affecting gut motility.
3) Pill bezoar.

Also, did the take all the pills at once? Cause the nromogram is supposed to be only for single acute ingestion.

 

[wreagle96]

wife confirmed time/amount of pills - all taken at once after fight with wife. apparently they made up enough that she called ems 3 hours later. he was sitting at the table responsive and normal RR when they showed. nothing else claimed to have been taken - other home meds were tramadol and crestor.

i was leaning towards the bezoar theory but didnt find much literature support.

 

[deleted6669]

maybe he took more as an inpatient because he would rather die than eat icu food.....

 

[EctopicFetus]

Also, with massive OD (35g) the pharmacokinetics/pharmacodynamics arent as straight forward.

 

[BADMD]

Opiates will absolutely delay the absorption. Assuming that your 4 and 8 hour levels are truly 4 hours apart, you already have the suggestion of wonky kinetics; I'd expect the 8 hour level to be below 50 mcg/ml. The normal AST and ALT at 24 hours is also a touch odd. I'd expect to see them slightly higher, although you see the bump at 24-36h post ingestion.

What I really, have a hard time believing is that with a huge overdose of an IR opiate, he suddenly becomes symptomatic from the opiate 36 hour later.

I would suspect a second ingestion. Bezoar might explain it, but I'd still think second ingestion.

 

[Rendar5]

I agree, someone prolly slipped him another bottle of percs/vicodins.

 

[EM2BE]

Was the pt given any anticholinergics? And I would most highly suspect a 2nd ingestion with this case.

Also, I don't know how things are done everywhere, but why were they still in your care? Most places I've been would have d/c'd the pt at the 8 or 24 hour time, or at least referred to psychiatry and sitting waiting for a bed. If the APAP level was neg at 24 hrs (if it were checked) without any significant liver issues, the pt would have been discharged to psych the few places I've been.

 

[RustedFox]

Not a toxicologist, but possibilities seem to be what people have said/implied:

1) Lied/wrong about time of ingestion.
2) Coningestants affecting gut motility.
3) Pill bezoar.

Also, did the take all the pills at once? Cause the nromogram is supposed to be only for single acute ingestion.

I saw that episode of House, too. Not poking fun at you, that was really the "a-HA!" moment on some episode way back in season 3 or 4.

 

[Daiphon]

I saw that episode of House, too. Not poking fun at you, that was really the "a-HA!" moment on some episode way back in season 3 or 4.

Agree... that was an annoying episode.

I have seen pharmacobezoars in ASA frequently, typically after food/drink us reintroduced, so possible. But for this case my money's on re-ingestion.

-d

Sent from my DROID BIONIC using Tapatalk

 

[gro2001]

I saw that episode of House, too. Not poking fun at you, that was really the "a-HA!" moment on some episode way back in season 3 or 4.

Oh yeah? I must have missed that episode.

Agree... that was an annoying episode.

I have seen pharmacobezoars in ASA frequently, typically after food/drink us reintroduced, so possible. But for this case my money's on re-ingestion.

-d

Sent from my DROID BIONIC using Tapatalk

Yes, I think you are right, the suddenly becoming symptomatic from opiates really suggests a second dose.

 

[wreagle96]

Pt was admitted to ICU for observation/monitoring due to the stated large amount of drugs ingested (which was confirmed by spouse). i am at a small critical access hospital that had a census of 3 at the time - may have played into the admission. Not much support around here for re-ingestion, but you never know.

 

[aglo123]

I'm no toxicology expert, but according to this site: http://lostallhope.com/suicide-methods/drug-poisoning/drug-mlds, the lethal dose of APAP is about 13g, this person exceeded that by a factor of nearly 3! This would lead me to agree with those above me that They either took a second dose or a bezoar formed, which I'm assuming is unlikely.