Fatal anaphylactoid reaction to N-acetylcysteine: caution in patients with asthma

Abstract

Successful thoracotomy in the prehospital environment is becoming more widely accepted.1 2 Here we present the case of cardiac arrest secondary to penetrating chest injury and the successful prehospital thoracotomy that followed. The resuscitation was associated with the spontaneous return of motor activity and later, hospital discharge. The implication for the immediate need for anaesthesia and paralysis is discussed together with a description of the surgical technique. CASE REPORTA teenage male youth sustained a stab wound to the left chest, in the third intercostal space at the junction of the medial and middle thirds of the clavicle. This wound was part of a deliberate self harm attempt. On arrival of the medical team-15 minutes from 999 call-he was thrashing and taking a few agonal breaths, this rapidly deteriorated to cardiac arrest within the first few seconds of assessment.The patient was placed on the floor of his first floor flat and endotracheal intubation was undertaken by the medical team paramedic; cannulation was achieved by a first responder paramedic and the medical team doctor undertook bilateral thoracostomies in the right and left 4th intercostal space, midaxillary line. This revealed a small haemothorax on the left side. The thoracostomies were joined by a skin incision using a 22 blade scalpel through skin and subcutaneous fat. Heavy duty shears were placed through the thoracostomy and used to cut through muscle and sternum thus making a large clamshell thoracotomy.With the chest open the pericardium was visualised as a blue, tense sac. Mosquito forceps were used to tent the pericardium and it was incised with scissors and widely opened. A large clot was removed and the operator's right index finger used to occlude a hole in the posterior aspect of the left upper heart. As the hole was occluded the heart began to fill and beat, restoring a carotid pulse. There was no anterior wound.The patient attempted to breathe and then localised both upper limbs towards the chest incision. He was rapidly sedated and paralysed with midazolam 10 mg and pancuronium 8 mg. The patient was then lifted down two flights of stairs and taken to the nearest accident and emergency/cardiothoracic centre still with digital occlusion of the hole. Treatment at scene lasted 18 minutes. Bleeding from the internal mammary vessels was controlled with mosquito forceps.On arrival, (journey time four minutes) he was maintaining a heart rate of 100 beats per minute and a systolic blood pressure of between 60 and 90 mm Hg. A cardiothoracic response enabled haemostatic sutures to be placed while in the resuscitation room before transfer to theatre for definitive closure. He was then transferred to the intensive care unit.The postoperative course was initially difficult requiring a second thoracotomy for intrathoracic bleeding. Sepsis caused a syndrome of renal failure requiring haemofiltration. However by day eight he was alert and appropriate neurologically, requiring no cardiovascular support and doing well. Subsequently he m...

N-Acetyl Cysteine Anaphylaxis in Seventeen Years-Old Child: Case Report

“…4 İV NAC tedavisine bağlı yan etkiler genellikle hafif olmakla birlikte, az sayıda hastada anafilaktoid reaksiyon bildirilmiştir. 2,6,7 Erişkin-lerde yapılan bir çalışmada, NAC'a bağlı ciddi yan etkiler (bronkospazm, anjiyoödem, hipotansiyon, taşikardi, dispne) hastaların %3'ünde bildirilmiş-tir. 2 Bu çalışmada yan etki gelişen hastaların yarısı NAC'ın verilmesi gerekenden daha fazla dozda verildiği hastalardır.…”

“…7 Appelboam ve ark.nın bildirdiği astım öyküsü olan erişkin hastada ise tedavi dozunda NAC verilmesine rağmen anafilaktoid reaksiyon gelişmiştir. 6 Olgumuzun ise erişkin literatüründen farklı olarak allerjik hastalığı veya astım öyküsü bulunmamakta idi.…”

“…3,6 Bir çalışmada, hastaların %15'inde IV NAC infüzyonunun başlamasından sonraki ilk iki saat içinde anafilaktoid reaksiyonların görüldüğü bildirilmiştir. 3,6 Olgumuzda da literatüre benzer şe-kilde NAC infüzyonunun birinci saatinde anafilaksi gelişmişti.…”

“…Hafif yan etkilerde infüzyonun durdurulması ve antihistaminik verilmesi ile semptomlar düzelmektedir. 6,7,12 Olgumuzda da NAC infüzyonunun durdurulması ve intramuskü-ler adrenalin verilmesinden kısa bir süre sonra anafilaksi semptomları gerilemiştir.…”

“…Geçmişte NAC tedavisine bağlı olarak gelişen anafilaktik reaksiyonlar genelde erişkin hastaları kapsamaktadır. 6 Bu çalışmada, intihar girişimi amacıyla parasetamol tablet içen, öyküsünde herhangi bir allerjik hastalık olmayan ve NAC tedavisi sırasında anafilaksi gelişen ergen bir olgu NAC'ın ciddi yan etkilerine dikkat çekmek amacıyla sunulmuştur.…”