Our friend, Lisa Booze over at Maryland poison center (mdpoison.com), recently released this toxicology update surrounding medication errors using Acetylcysteine, the antidote for acetaminophen overdoses.

This medication is administered in the hospital setting but it is important to understand some aspects of patients with acetaminophen overdoses.  One of the items that Lisa lists below as a problem with the acetaminophen overdose treatment is the delay in treatment.  EMS providers can help with that.

When you have a patient who may have ingested a large dose of Tylenol (acetaminophen) or of a medication containing this drug, like many cough and cold medications, involve your poison center quickly in the loop along with your medical control docs to get these patients in the loop and have the ER ready to receive these patients and get the necessary tests completed quickly on arrival.

Lisa talks about other aspects of this treatment below. Check out what she has to say below:

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Maryland Poison Center Toxtidbit -Acetylcysteine Medication Errors

Acetylcysteine is a commonly used antidote to prevent or limit the hepatotoxicity associated with acetaminophen overdoses. It was first approved in 1985 by the FDA to be administered orally.  An intravenous preparation of acetylcysteine was approved in 2004 and is currently sold as Acetadote®. The intravenous dosing regimen is somewhat complex in that a loading dose followed by 2 maintenance doses are all given at different infusion rates:

• 150 mg/kg in 200 mL D5W over 1 hour
• 50 mg/kg in 500 mL D5W over 4 hours
• 100 mg/kg in 1000 mL D5W over 16 hours

In order to assess the frequency of errors in the administration of IV acetylcysteine, a retrospective chart review of Maryland Poison Center records of patients treated with IV acetylcysteine from August 1, 2006 to August 31, 2007 was performed.  The results of this study were recently published:

Hayes BD, Klein Schwartz W, Doyon S. Frequency of medication errors with intravenous acetylcysteine for acetaminophen overdose. Ann Pharmacother 2008;42:766-70.

There were 84 medication errors identified in 74 (33%) of 221 patients. Errors occurred more frequently in emergency departments (54% of cases) as compared to medical floors, ICU’s and during patient transfers, and occurred more commonly on third shift. The types and frequency of errors included:

• More than one hour of interruption between doses (especially between the 2nd and 3rd dose)—18.6%
• Unnecessary administration—13.1%
• Incorrect infusion rate (including 5 cases of administering the loading dose over 15 minutes instead of 1 hour, as was recommended until 2006)—5.0%
• Incorrect dose—1.4%

Hospital staff should be aware of the potential for IV acetylcysteine administration errors and take steps to prevent these errors. When consulted, the Maryland Poison Center works closely with physicians, nurses and pharmacists to ensure that acetylcysteine is administered correctly.

DID YOU KNOW THAT… anaphylactoid reactions to intravenous acetylcysteine sometimes occur?

Adverse effects including rash, pruritus, angioedema, bronchospasm, tachycardia, and hypotension have occurred in a small number of patients.  The frequency of adverse effects reported in the literature ranges from 0.2% to 20%, but is generally accepted to be less than 10%. In most cases, adverse effects are mild and do not require discontinuing treatment with IV acetylcysteine. Call the Maryland Poison Center for assistance in assessing and managing adverse effects with IV acetylcysteine.

1-800-222-1222 National Poison Control Number

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You can get email notification of new versions of the Maryland Poison Center’s ToxTidbits and ToxAlert newsletters.  Sign up for free here (you don’t have to live in Maryland to get these).

Hear more of Lisa Booze here on the MedicCast each month with a featured segment on toxicology and medication overdoses just for MedicCast listeners.

Check out past episodes below:

MedicCast Live Episode on Poison Control Centers

Insecticide Poisonings

Acetaminophen OD

Household Cleaner Poisonings

Dextromethorphan OD

Snakebites

Poison Control Centers

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