Massive Ibuprofen Ingestion Resulting in Coagulopathy, Hypotension, and Coma without Significant Renal Failure
Cole, JB; Roberts, DJ; Bangh, SA
Taylor & Francis Ltd., 11 New Fetter Lane London EC4P 4EE UK, [URL:http://taylorandfrancis.metapress.com]
Background: Serious toxicity from ibuprofen ingestion includes coma, metabolic acidosis, GI bleeding, shock, and death. Renal failure is common. Cases of isolated massive ingestion are rare. Review of the literature reveals the highest reported ingestion was 100 grams. We report an isolated massive ibuprofen overdose of 100 grams with coagulopathy, hypotension and coma without renal failure. Case Report: An 18 yo previously healthy male was found down with a suicide note and an empty bottle of ibuprofen that contained five hundred 200mg tablets. The patient later admitted to making a slurry and consuming the entire bottle. On arrival to the ED, the patient had a GCS of 4 with no gag reflex and was intubated. He was hypotensive and required norepinephrine and dopamine. He had a negative comprehensive urine drug screen for drugs of abuse and other medications. He also had negative carbon monoxide, acetaminophen, salicylate, ethanol, ethylene glycol, and methanol levels. A serum ibuprofen level drawn immediately in the ED was 262 mcg/ml (normal range 10-50 mcg/ml). Time of ingestion was unknown, but was at most 6 hours prior to arrival. Despite vomiting at the scene and receiving activated charcoal, an ibuprofen level 24 hours after admission was 514 mcg/ml. Admission labs included an INR of 2.9 that peaked at 8.4 two days later, a PTT that was >150, and a pH of 7.17 with an anion gap of 15 that peaked 6 hours later at 22. Renal function was normal throughout his stay. The patient was extubated on day 2, pressors were weaned by day 3, and he was discharged on day 8 to a psychiatric facility with no significant sequelae. Case Discussion: In the previous case of 100 gram ingestion, the admission level was 720 mcg/ml and 16 hours later was 16 mcg/ml. Our case resembles the previous case of a 100 gram overdose in that both patients developed an anion gap acidosis with no significant renal failure, but differs in that our patient became coagulopathic, hypotensive and had toxic levels which persisted beyond those previously reported. Conclusion: The effects and toxicokinetics of massive ibuprofen overdose are variable, and renal injury is not inevitable.
Bleeding; Ibuprofen; Urine; Tablets; Anions; Dopamine; Ethylene glycol; Injuries; Suicide; Acidosis; Drug abuse; Slurries; Methanol; Acetaminophen; Case reports; Charcoal; Renal function; Vomiting; Norepinephrine; Carcinoembryonic antigen; Ethanol; Coma; Overdose; Renal failure; pH effects; Hypotension; Shock; Complications; Salicylic acid; Toxicity