238.A 40-year-old man with a known history of ethanol abuse states that
2 hours ago he ingested two bottles of extra-strength Tylenol. The patient
has no medical complaints except for some nausea. At 4 hours post inges-
tion you send blood to the laboratory to measure the serum acetaminophen
concentration. The level returns and falls above the treatment line when
you plot it on the APAP nomogram. You administer activated charcoal and
decide to start IV NAC. Which of the following is a known adverse effect of
IV NAC administration?
a. Hepatic failure
b. Anaphylactoid reaction
c. Hypertensive crisis
d. Confusion
e. Change in urine color
239.A 19-year-old woman presents to the ED with abdominal pain, nausea,
vomiting, diarrhea, and hematemesis after ingesting an unknown substance
in a suicide attempt. Which of the following antidotes are correctly paired?
a. Organophosphate—Physostigmine
b. Iron overdose—Deferoxamine
c. Aspirin overdose—NAC
d. Benzodiazepine overdose—Narcan
e. Anticholinergic overdose—Fomepizole
240.A 34-year-old woman presents to the ED after ingesting an unknown
quantity of her antidepressant pills. EMS workers found an empty bottle of
amitriptyline on her apartment floor. She is awake but appears delirious. Her
BP is 130/65 mm Hg, HR is 101 beats per minute, temperature is 99.1°F, R R
is 16 breaths per minute, and oxygen saturation is 100% on room air. On
examination, her pupils are 7 mm and reactive. Her face is flushed and mucous
membranes are dry. Her lungs are clear and heart is without murmurs. The
abdomen is soft, nontender, and with decreased bowel sounds. She is mov-
ing all four extremities. ECG reveals sinus rhythm at a rate of 99 and QRS just
under 100 msec. In a tricyclic antidepressant (TCA) overdose, which of the
following is responsible for her mydriasis, dry mucous membranes, and
delirium?
a. Sodium channel blockade
b. Muscarinic receptor blockade
c. Inhibition of serotonin and norepinephrine reuptake
d. Histamine receptor blockade
e. α-Receptor blockade
246 Emergency Medicine