Which is the Treatment of Choice for Acute Acetaminophen Overdose in a Situation Where a Serum Level Determination is Not Available Within 8 Hours: Oral or Intravenous N-Acetylcysteine Treatment?

PURPOSE: The purpose of this study was to develop therapeutic decision guidelines on N-acetylcysteine (NAC) treatment for acetaminophen (AAP) overdose in a situation where a serum level determination is not available within 8 hours. METHODS: We reviewed retrospectively the medical records of patients admitted for AAP overdose from January 2001 to February 2004. Forty-nine patients met inclusion criteria; patients with acute AAP overdose who were exposed to 7.5 g or 140 mg/kg or greater, determination of the serum level was not available within 8 hours, and NAC treatment was started empirically before identification of the serum level. The patients had been treated with a 72hour oral or a 20hour intravenous (IV) NAC treatment protocol. RESULTS: Patients were classified into an Oral NAC (n=24) group and an IV NAC (n=25) group based on the treatment protocol. There were no significant intergroup differences in patient characteristics, time variables, distribution of risk categories, and hepatotoxicity. All the patients in both toxic groups were fully recovered, and the difference in the number of adverse reactions during NAC treatment were not significant between the two groups (Oral NAC vs IV NAC, 4 (16%) vs. 2 (8%), respectively; p=0.417). The numbers of patients who discontinued the NAC treatment were 14 (58%) in the Oral NAC group and 8 (32%) in the IV NAC group (p=0.088). The six patients in the nontoxic category of IV NAC group were already completed before determination of the serum level. CONCLUSION: Therapeutic decisions for AAP overdose which are based entirely on ingestion history have some limitations. IV NAC is as effective as oral treatment for patients with acute AAP overdose. If the serum level is not available within 8 hours, the clinician should preventively administer the first dose of oral NAC to patients without severe vomiting. Subsequently, when the serum level is determined, the need for additional therapy should be determined to reduce unnecessary use of NAC. However, if the patients present with severe vomiting or contraindications to oral treatment, intravenous administration is required.

Retroperitoneal Ectopic Pregnancy: A Case Report

A retroperitoneal ectopic pregnancy is a very rare form of extrauterine pregnancy and is a potentially life threatening variation of ectopic gestation within the retroperitoneal cavity. In fact, the clinical history, physical examination, laboratory and vaginal ultrasonographic findings are non specific. It is a surgical emergency because of high maternal and fetal morbidity and mortality. Early diagnosis is essential. Surgical intervention is indicated as soon as the diagnosis is made. We report our experience with one retroperitoneal ectopic pregnancy with a brief review of the literature

Torsion of an Accessory Spleen Presenting as an Acute Abdomen: A Case Report

An accessory spleen is often incidentally discovered in up to 20% of autopsies. However, it is exceedingly rare for this condition to result in an acute abdomen. In addition, torsion of an accessory spleen is extremely rare. In spite of this, the entity should be considered in the emergency department in the differential diagnosis of an acute abdomen associated with an intraperitoneal inflammatory mass. This report describes a case of acute torsion of an accessory spleen. A 26-year-old, previously health female was admitted to our hospital with severe abdominal pain and a palpable mass. Ultrasonography showed a well-defined ovoid, hypoechogenic, avascular mass. Computed tomography demonstrated a round, homogeneous hypodense mass with a whorling appearance and an engorged vascular structure in the left side of the mass. The presumptive diagnosis of a large exoenteric mass (small bowel or mesenteric origin) associated with mesenteric volvulus was made preoperatively. However, at laparotomy, the patient was found to have torsion and an infarction of an accessory spleen that had twisted on its long vascular pedicle.

Tension Pneumocephalus

This paper presents one case of subdural tension pneumocephalus which deteriorated in the early phase of head trauma. Pneumocephalus occurs in 0.5 to 1.0% of head trauma cases. Most patients have nonspecific signs and symptoms, such as headache. Therefore, a high index of suspicion in a patient with recent head trauma is necessary. Therapy is often noninvasive, allowing the craniodural defect to heal spontaneously. However, if enough air collects within the cranium or the brain itself, a mass effect with marked midline shift may develop. This is referred to as tension pneumocephlus and may result in herniation symdrome. Prompt decompression is essential.