This is another toxicology case that illustrates a point I make (probably too often) to my residents – that every action we take has a risk of harm, whether known or unanticipated. I’m probably the only attending who cancels their IM ketorolac orders and changes them to PO ibuprofen. Why? Because of cases like this.
This is an entirely appropriate therapy – N-acetylcysteine given for hydrocodone-acetaminophen overdose – gone wrong because of a mixing error resulting in 10-fold overdose (126,000mg loading dose!). Anaphylactoid reactions are known side effects in N-acetylcysteine, and, unfortunately, this patient’s reaction was more severe than most, suffering an inferior MI with a peak troponin of 658ng/mL. He expired 17 hour after the N-acetylcysteine overdose.
I’ve seen epinephrine given IV instead of SQ more than once (one time resulting in an MI), many medications are tissue toxic if they extravasate, you can get sterile abscess formation from intramuscular injections, etc. The fewer interventions and the less invasive the interventions, the less risk at which we place our patients.
“Fatal myocardial infarction associated with intravenous N-acetylcysteine error”