CASE

A;-2qpreviously well 31/2-year-old, 13-kg female        accidentally ingested 240 mg/kg of acet       aminophen. She was brought to a local hospital where her blood work 4 hours after ingestion showed a serum sodium of 141 mmol/L and an acetaminophen level of 1701 µmol/L. A drug screen was negative for barbiturates, salicylates, and ethanol. She received charcoal and intravenous (IV) N-acetylcysteine (NAC) according to the 20-hour protocol outlined in the Canadian product monograph. For a patient of this weight, the monograph suggests a loading dose of 11.25 mL of 20% NAC mixed with 40 mL of 5% dextrose for administration over 15 minutes. The maintenance infusion is then 3.75 mL of NAC in 500 mL of 5% dextrose over 4 hours, followed by 7.5 mL of NAC in 1 L of 5% dextrose over 16 hours. Approximately 9 hours after the initiation of NAC therapy, the patient experienced two brief generalized seizures; she received IV diazepam for the first. Subsequently, she had a 21-minute generalized tonic-clonic seizure and required intubation with pentothal anaesthesia. She was then transported to the nearest tertiary care pediatric center. Before transport, her serum sodium was 118 mmol/L.

On arrival at the pediatric center, she had generalized increased tone and mild hyperreflexia; her serum sodium was 122 mmol/L. She was given a continuous infusion of 3% sodium chloride, which led to an increase in her serum sodium to 129 mmol/L after 10 hours. . . . [Full Text of this Article]