Use of fomepizole, n-acetylcysteine, and hemodialysis for massive acetaminophen overdose

Acetaminophen poisoning is the leading cause of liver transplantation within the United States, accounting for nearly 56,000 emergency department patient visits each year. Although n-acetylcysteine is commonly successful in preventing acetaminophen toxicity when given in a timely manner, reports do exist demonstrating n-acetylcysteine therapy failure, commonly in the setting of a massive ingestion. We present the use of a novel antidote cocktail of n-acetylcysteine, fomepizole, and hemodialysis to treat a massive acetaminophen ingestion. A 55-year old male with a past medical history significant for bipolar disorder and past suicidal ideation presented to the emergency department after being found unresponsive at home. Medical workup was significant for an estimated seven-hour acetaminophen level of 883 mcg/mL, with concomitant metabolic acidosis. The patient was diagnosed with severe acetaminophen poisoning and was promptly administered n-acetylcysteine. Due to the severity of the patient’s ingestion and the concern for additional coingestants, the patient was also given fomepizole therapy and later underwent hemodialysis for more rapid toxin clearance. After a four-day stay in the hospital the patient was discharged to a mental-health facility with no signs of systemic injury.