Poisoning and Overdose 243232.A 26-year-old woman, who was found lying on the floor of her apart-
ment next to an unlabeled empty pill bottle, is brought into the ED. Her
HR is 117 beats per minute, BP is 95/65 mm Hg, RR is 14 breaths per
minute, and oxygen saturation is 97% on 2-L nasal cannula. On examina-
tion, the patient appears obtunded, her pupils are 3 mm and reactive. Her
oropharynx is dry and there is no gag reflex to pharyngeal stimulation. Her
neck is supple. The heart is tachycardic without murmurs, the lungs are
clear to auscultation, and the abdomen is soft. There is normal rectal tone
and brown stool that is heme negative. Her skin is cool and moist with no
signs of needle tracks. Neurologically, she is unresponsive, but withdraws
all extremities to deep palpation. Finger stick blood glucose is 85 mg/dL.
Her ECG reveals sinus tachycardia at 119 with a QRS complex of 120 msec
and a terminal R wave in lead aVR. Which of the following is the most
appropriate next step in management?
a. Orotracheal intubation, administer activated charcoal through orogastric
tube, and IV Narcan
b. Orotracheal intubation, administer activated charcoal through orogastric tube,
and IV sodium bicarbonate
c. Orotracheal intubation, administer activated charcoal through orogastric tube,
and IV NAC
d. Orotracheal intubation, administer syrup of ipecac through orogastric tube, and
IV sodium bicarbonate
e. Induce vomiting prior to intubation to lower the risk of aspiration then admin-
ister IV sodium bicarbonate
233.A 37-year-old woman is brought into the ED by her friend who
states that the patient swallowed approximately 50 capsules of 325-mg
acetaminophen 6 hours ago in an attempted suicide. The patient states she feels
nauseated and vomits while you take her history. Her BP is 100/75 mm Hg,
HR is 97 beats per minute, temperature is 98.9°F, RR is 18 breaths per
minute, and oxygen saturation is 99% on room air. Examination is unre-
markable except for mild epigastric tenderness. Which of the following is the
correct antidote for APAP overdose?
a. NAC
b. Physostigmine
c. Flumazenil
d. Naloxone
e. Digibind