A 20-year-old college student is brought to the emergency department by his girlfriend after he ingested large amounts of acetaminophen in a suicide attempt. Two days ago, the girlfriend told the patient that she wanted to break up with him. He became distraught and took approximately 30 pills of 500-mg acetaminophen to end his life. This morning, the girlfriend discovered what he had done and brought him in to seek care. The patient reports nausea and mild abdominal pain. He has no history of previous suicide attempts or psychiatric illness. Temperature is 36.7 C (98 F), blood pressure is 114/68 mm Hg, and pulse is 94/min. Abdominal examination reveals mild tender hepatomegaly. Serum acetaminophen level is high, and the patient is hospitalized for N-acetylcysteine therapy. During the hospital stay, he becomes markedly confused and incoherent. Repeat examination shows scleral icterus and asterixis. Current laboratory results and those obtained at the time of admission are as follows: Which of the following is the best next step in management of this patient?

Question

A 20-year-old college student is brought to the emergency department by his girlfriend after he ingested large amounts of acetaminophen in a suicide attempt.  Two days ago, the girlfriend told the patient that she wanted to break up with him.  He became distraught and took approximately 30 pills of 500-mg acetaminophen to end his life.  This morning, the girlfriend discovered what he had done and brought him in to seek care.  The patient reports nausea and mild abdominal pain.  He has no history of previous suicide attempts or psychiatric illness.  Temperature is 36.7 C (98 F), blood pressure is 114/68 mm Hg, and pulse is 94/min.  Abdominal examination reveals mild tender hepatomegaly.  Serum acetaminophen level is high, and the patient is hospitalized for N-acetylcysteine therapy.  During the hospital stay, he becomes markedly confused and incoherent.  Repeat examination shows scleral icterus and asterixis.  Current laboratory results and those obtained at the time of admission are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient has acute liver failure (ALF) due to acetaminophen toxicity. ALF is defined as severe acute liver injury without underlying liver disease and is characterized by elevated aminotransferases (often >1,000 U/L), hepatic encephalopathy, and synthetic liver dysfunction (defined as prolonged prothrombin time [PT] with INR >1.5). Approximately only half of patients with ALF will survive without liver transplantation. Reliable indicators of worsening ALF include rising serum bilirubin and PT, as seen in this patient. Acute renal insufficiency, likely due to decreased renal perfusion, is common and portends a lower chance of recovery without liver transplantation. The degree of hepatic encephalopathy is also of prognostic importance as grade III hepatic encephalopathy (characterized by marked confusion and incoherence) is associated with an only 40%-50% chance of spontaneous recovery. Cerebral edema is a potential complication of ALF that may lead to coma and brain stem herniation, and is the most common cause of death. > The ethical considerations are complicated regarding liver transplantation for ALF due to a suicide attempt; however, in a patient with reactive depression and no history of psychiatric illness or previous suicide attempt, liver transplantation is typically pursued if needed. In ALF due to acetaminophen toxicity, liver transplantation is firmly indicated in patients with grade III or IV hepatic encephalopathy, PT >100 seconds, and serum creatinine >3.4 mg/dL (as in this patient). One-year survival following liver transplantation for ALF is approximately 80%. (Choices A and C) Liver biopsy is sometimes helpful in ALF of unclear etiology. This patient's ALF is due to acetaminophen toxicity and his condition is worsening. Close monitoring alone would not be appropriate, and liver biopsy is unlikely to prevent the need for liver transplantation. (Choice B) This patient's prolonged PT reflects coagulopathy due to ALF rather than due to vitamin K deficiency (often seen in patients with malnutrition). As a result, vitamin K supplementation will have limited effect on this patient's coagulopathy. (Choice E) Glucocorticoids are generally not indicated in ALF as they increase the risk of infection and have not demonstrated benefit in most etiologies of ALF. They may provide benefit in alcoholic hepatitis and in ALF due to autoimmune hepatitis. Educational objective: Survival without liver transplantation is low in patients with acute liver failure and indications that the disease is worsening or failing to improve. When appropriate, these patients should undergo early consideration for liver transplantation. References: Determinants of outcome among patients with acute liver failure listed for liver transplantation in the United States. (http://www.ncbi.nlm.nih.gov/pubmed/26421889) Fulminant hepatic failure: etiology and indications for liver transplantation. (http://www.ncbi.nlm.nih.gov/pubmed/17890263) Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study. (http://www.ncbi.nlm.nih.gov/pubmed/16317692)

A 20-Year-Old College Student Is Brought to the Emergency Department