Sat27November0556PM 25

A 24-year-old man presented twelve hours after a staggered overdose of dihydrocodeine 1.2 g and paracetamol 30 g.

He has 3 mm pupils, a Glasgow coma scale (GCS) score of 14, respiratory rate of 14, and blood pressure of 100/60 mmHg.

Which one of the following is the most appropriate management?

(Please select 1 option)

Intravenous naloxone

Oral activated charcoal

500 ml of 10% glucose intravenously over four hours

Intravenous N-acetylcysteine Correct

Intravenous flumazenil

Explanation

This patient's GCS is reasonable and the opiate-like effects seem minimal (no evidence of respiratory depression). Intravenous naloxone is therefore not currently required, but the patient should be closely monitored.

However, this patient has received a significant dose of paracetamol, over a staggered period, conferring a high risk of hepatic toxicity. The 12 hour delay makes the absorptive effects of charcoal limited and although it would be useful as gastric emptying may be delayed it is not as important in this patient as the paracetamol antidote. The paracetamol level is not used to guide treatment in the setting of a staggered overdose, and N-acetylcysteine should be given without delay to reduce the risk of liver failure.

There is no evidence of hypoglycaemia or benzodiazepine overdose so neither dextrose or flumazenil are required.

Answer Statistics

1

8%

2

1%

3

1%

4

91%

5

1%

Times answered: 298