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Ibuprofen blood levels vary
CORRESPONDENCE
Ibuprofen Blood Levels Vary To the Editor: We welcomed the Hall et al article, "Ibuprofen Overdose: 126 Cases" [November 1986; 15:1308-1313] in its presentation of their nomogram and concise discussion of ibuprofen overdose symptomatology. We would like to add a sampling of four patients ingesting ibuprofen (and in w h o m levels were obtained) presenting to our emergency department within the previous six months. Case I. An 18-year-old, 70-kg w o m a n presented four hours after ingestion of 50 600-mg ibuprofen tablets {428 mg/kg). She was alert and asymptomatic. Her physical examination was unremarkable except for superficial lacerations over the volar aspects of her wrists. The patient's vital signs were blood pressure, 130/90 m m Hg; pulse, 76; respirations, 20; and afebrile. Treatment consisted of ipecac, activated charcoal with sorbitol, and tetanus-diphtheria toxoid. Toxicology screen five hours after ingestion demonstrated only ibuprofen at 38 ~g/mL. Serum electrolytes, BUN, and creatinine were all within normal limits. The patient remained asymptomatic and was transferred for psychiatric evaluation after six hours observation in the ED. Case 2. An 18-year-old, 75-kg man was transported to the ED after ingestion of 80 600-mg ibuprofen tablets (640 rag/ kg). The patient was obtunded, and responded only to noxious stimuli with combative behavior, without verbalization. Physical examination was otherwise remarkable only for nonreactive, 1-mm pupils. Vital signs were blood pressure, 120/60 m m Hg; pulse, 130; and respirations, 20. No response was noted with naloxone or DS0 W. The patient was intubated and paralyzed with vecuronium prior to gastric lavage and gastric installation of activated charcoal and sorbitol. Toxicology screen two hours after ingestion demonstrated ibuprofen level of 520 ~g/mL; ethanol, 106 mg%; and salicylates, 3.5 mg%. He remained intubated for 12 hours, and intermittent episodes of hypotension (systolic blood pressure, 80 to 100 mg Hg) were treated with isotonic fluid boluses. Subsequent ibuprofen levels at 4, 6.5, and 11.5 hours after ingestion were 320 p,g/mL, 124 ~g/mL, and 9.5 p,g/mL, respectively. Of note, this patient developed a severe hypophosphatemia (PO4, 0.8 mg/dL), as well as a hypokalemia {requiring 160 mEq KC1 IV over the first 12 hours to maintain K + at 3.6 mEq/L) following his ingestion. He was discharged six days after admission after noting a mild rise in AST (33 to 61 IU/L), ALT (30 to 80 IU/L) and LDH {207 to 386 IU/L), which subsequently resolved. Renal failure never developed. He developed chicken pox two days after admission.
Case 3. A 16-year-old, 55-kg girl presented two hours after ingestion of 28 600-mg ibuprofen tablets (305 mg/kg). She was alert with complaints of headache and tinnitus. Physical examination was unremarkable. Vital signs were blood pressure, 150/82 m m Hg; pulse, 118; respirations, 16; and afebrile. Treatment consisted of naloxone, ipecac, and activated charcoal with sorbitol. Toxicology screen at four hours after ingestion reported only ibuprofen at 37 ~g/mL. Serum electrolytes, BUN, and creatinine were all normal. The patient remained asymptomatic and was discharged after six hours of observation in the ED. Case 4. A 21-year-old woman presented one hour after ingestion of 20 800-mg ibuprofen tablets (200 mg/kg). She was alert and asymptomatic, with an unremarkable physical examination. Vital signs were blood pressure, 142/74 m m Hg; pulse, 92; respirations, 20; and afebrile. Treatment consisted of ipecac and activated charcoal with sorbitol. Toxicology screen two hours after ingestion demonstrated only trace ibuprofen in the blood. She remained asymptomatic, and was transferred for psychiatric evaluation after six hours of observation in the ED. These four cases demonstrate the variability of measured ibuprofen blood levels, reported a m o u n t s ingested, and syrnptomatology in adults; as such, they correlate well with the findings of Hall et al. Of interest is our second case, in which the patient developed a marked potassium and phosphate deficit following ingestion. There is no reason to suspect that this was due to either the other drugs he ingested or was iatrogenic in nature. These abnormalities have not been described previously in ibuprofen ingestions. Though the rise in AST, ALT, and LDH was minor, it is difficult to determine if this was sec o ondary to his ingestion or his exposure to varicella. These evaluations are not clinically signifieant and have been noted previously1, ~ in those taking normal quantities of ibuprofen, but not in single-dose ingestions. Fred Harchelroad Jr, MD Timothy C Evans, MD Elgin Hobbs, MD Division of Emergency Medicine Allegheny General Hospital Pittsburgh, Pennsylvania 1. Stempel DA, Miller JJ: Lymphopenia and hepatic toxicity with ibuprofen, l Pediatr 1977;90:657-658. 2. Royer GL, Seckman CE, Welshman IR: Safetyprofile: Fifteen years of clinical experiencewith ibuprofen. Am l Med 1984~77:25-34.
Cocaine Abuse and Unusual Injection Sites To the Editor: As the illicit use of cocaine has continued to increase, so too have cocaine-related emergency department visits, hospital admissions, and deaths.~ Cocaine is most often taken 118/186
mtranasally.Z It also may be injected subcutaneously, IM or IV; taken orally, vaginally, sublingually, or rectally; and may be smoked, a For the IV drug abuser, potential routes of ad-
Annals of Emergency Medicine
17:2 February 1988
Ibuprofen Blood Levels Vary To the Editor: We welcomed the Hall et al article, "Ibuprofen Overdose: 126 Cases" [November 1986; 15:1308-1313] in its presentation of their nomogram and concise discussion of ibuprofen overdose symptomatology. We would like to add a sampling of four patients ingesting ibuprofen (and in w h o m levels were obtained) presenting to our emergency department within the previous six months. Case I. An 18-year-old, 70-kg w o m a n presented four hours after ingestion of 50 600-mg ibuprofen tablets {428 mg/kg). She was alert and asymptomatic. Her physical examination was unremarkable except for superficial lacerations over the volar aspects of her wrists. The patient's vital signs were blood pressure, 130/90 m m Hg; pulse, 76; respirations, 20; and afebrile. Treatment consisted of ipecac, activated charcoal with sorbitol, and tetanus-diphtheria toxoid. Toxicology screen five hours after ingestion demonstrated only ibuprofen at 38 ~g/mL. Serum electrolytes, BUN, and creatinine were all within normal limits. The patient remained asymptomatic and was transferred for psychiatric evaluation after six hours observation in the ED. Case 2. An 18-year-old, 75-kg man was transported to the ED after ingestion of 80 600-mg ibuprofen tablets (640 rag/ kg). The patient was obtunded, and responded only to noxious stimuli with combative behavior, without verbalization. Physical examination was otherwise remarkable only for nonreactive, 1-mm pupils. Vital signs were blood pressure, 120/60 m m Hg; pulse, 130; and respirations, 20. No response was noted with naloxone or DS0 W. The patient was intubated and paralyzed with vecuronium prior to gastric lavage and gastric installation of activated charcoal and sorbitol. Toxicology screen two hours after ingestion demonstrated ibuprofen level of 520 ~g/mL; ethanol, 106 mg%; and salicylates, 3.5 mg%. He remained intubated for 12 hours, and intermittent episodes of hypotension (systolic blood pressure, 80 to 100 mg Hg) were treated with isotonic fluid boluses. Subsequent ibuprofen levels at 4, 6.5, and 11.5 hours after ingestion were 320 p,g/mL, 124 ~g/mL, and 9.5 p,g/mL, respectively. Of note, this patient developed a severe hypophosphatemia (PO4, 0.8 mg/dL), as well as a hypokalemia {requiring 160 mEq KC1 IV over the first 12 hours to maintain K + at 3.6 mEq/L) following his ingestion. He was discharged six days after admission after noting a mild rise in AST (33 to 61 IU/L), ALT (30 to 80 IU/L) and LDH {207 to 386 IU/L), which subsequently resolved. Renal failure never developed. He developed chicken pox two days after admission.
Case 3. A 16-year-old, 55-kg girl presented two hours after ingestion of 28 600-mg ibuprofen tablets (305 mg/kg). She was alert with complaints of headache and tinnitus. Physical examination was unremarkable. Vital signs were blood pressure, 150/82 m m Hg; pulse, 118; respirations, 16; and afebrile. Treatment consisted of naloxone, ipecac, and activated charcoal with sorbitol. Toxicology screen at four hours after ingestion reported only ibuprofen at 37 ~g/mL. Serum electrolytes, BUN, and creatinine were all normal. The patient remained asymptomatic and was discharged after six hours of observation in the ED. Case 4. A 21-year-old woman presented one hour after ingestion of 20 800-mg ibuprofen tablets (200 mg/kg). She was alert and asymptomatic, with an unremarkable physical examination. Vital signs were blood pressure, 142/74 m m Hg; pulse, 92; respirations, 20; and afebrile. Treatment consisted of ipecac and activated charcoal with sorbitol. Toxicology screen two hours after ingestion demonstrated only trace ibuprofen in the blood. She remained asymptomatic, and was transferred for psychiatric evaluation after six hours of observation in the ED. These four cases demonstrate the variability of measured ibuprofen blood levels, reported a m o u n t s ingested, and syrnptomatology in adults; as such, they correlate well with the findings of Hall et al. Of interest is our second case, in which the patient developed a marked potassium and phosphate deficit following ingestion. There is no reason to suspect that this was due to either the other drugs he ingested or was iatrogenic in nature. These abnormalities have not been described previously in ibuprofen ingestions. Though the rise in AST, ALT, and LDH was minor, it is difficult to determine if this was sec o ondary to his ingestion or his exposure to varicella. These evaluations are not clinically signifieant and have been noted previously1, ~ in those taking normal quantities of ibuprofen, but not in single-dose ingestions. Fred Harchelroad Jr, MD Timothy C Evans, MD Elgin Hobbs, MD Division of Emergency Medicine Allegheny General Hospital Pittsburgh, Pennsylvania 1. Stempel DA, Miller JJ: Lymphopenia and hepatic toxicity with ibuprofen, l Pediatr 1977;90:657-658. 2. Royer GL, Seckman CE, Welshman IR: Safetyprofile: Fifteen years of clinical experiencewith ibuprofen. Am l Med 1984~77:25-34.
Cocaine Abuse and Unusual Injection Sites To the Editor: As the illicit use of cocaine has continued to increase, so too have cocaine-related emergency department visits, hospital admissions, and deaths.~ Cocaine is most often taken 118/186
mtranasally.Z It also may be injected subcutaneously, IM or IV; taken orally, vaginally, sublingually, or rectally; and may be smoked, a For the IV drug abuser, potential routes of ad-
Annals of Emergency Medicine
17:2 February 1988