Combined Butalbital/Acetaminophen/Caffeine Overdose: Case Files of the Robert Wood Johnson Medical School Toxicology Service

Abstract

A 40-year-old woman with no previous medical problems presented to the Emergency Department (ED) 2 h after ingesting an unknown amount of Fioricet® (butalbital/acetaminophen/caffeine), oxycodone, and fentanyl patches about 90 min prior to emergency medical service (EMS) dispatch. The patient’s husband reported they had had a fight, and he went down to the basement; when he came back upstairs, he found the patient unconscious with an empty pill bottle. A call to the patient’s pharmacy by ED staff revealed that the patient had her prescription for butalbital/acetaminophen/caffeine tablets refilled 5 days earlier and that she had convinced the pharmacist to override the refill amount to dispense 540 tablets; according to the pharmacist, the patient stated she was going on a trip to Italy and needed a 6-month supply. EMS personnel removed a fentanyl patch (unknown strength) from her skin. The source of the fentanyl and the strength and formulation of the oxycodone were not recorded. Prehospital treatment included naloxone 4 mg IV without any noticeable clinical response, insertion of a nasal trumpet, and initiation of bag-valve-mask ventilation. A fingerstick glucose was 137 mg/dL. On arrival to the ED, the patient was unconscious with the following vital signs: blood pressure, 98/54 mmHg; pulse, 72 beats/min; respiratory rate, 14 breaths/min; and pulse oximetry, 100 % on a non-rebreather mask. Auscultation of her chest revealed clear but bilaterally diminished breath sounds and a regular cardiac rhythm without murmurs, rubs, or gallops. The patient’s ventilation improved with jaw thrust, but, due to increased secretions, she was intubated within 10 min of ED arrival using etomidate and succinylcholine. On further examination, she had palpable distal pulses, and her abdomen was soft and non-tender. The patient’s pupils were 1–2 mm in diameter and sluggishly reactive to light. The patient was noted to be shivering prior to being fully exposed, and her skin was warm and dry, revealing no signs of traumatic injuries. An ECG revealed a normal sinus rhythm at 86 beats per minute with a prolonged QTc interval (504 ms). An orogastric tube and Foley catheter were both inserted, with a large volume (700 cc) of dark-colored urine quickly filling the Foley bag. Activated charcoal 50 g was administered via orogastric tube. Due to the reported large ingestion of acetaminophen and some initial uncertainty about the time of ingestion, an IV N-acetylcysteine (NAC) infusion was started according to the 21-h protocol, prior to obtaining serum acetaminophen level results. About 90 min after arrival (3 h after ingestion), the patient began having massive diuresis, producing 5,800 cc of urine over 1 h. Due to concerns about the patient’s reported fentanyl patch ingestion and the lack of knowledge regarding possible extendedThis project was not funded.