The Choice: Tylenol or Aspirin

Pediatrics for Parents, Feb, 1999 by Monaco John E.

Recently, we have admitted an alarming number of teenage patients who have attempted suicide. Thankfully, all have been unsuccessful. It is impossible to estimate how many are successful before they get to the hospital.

Many have not used exotic or even very imaginative methods. In fact, their seems to be a rising preference for the old household favorites: Tylenol (acetaminophen) and aspirin. Both can be deadly and both offer opportunities to stress the need to take ALL medications seriously.

Since their actions and metabolism differ, the effects of overdose differ. Aspirin is metabolized to its basic components in the liver and excreted by the kidneys. It has several major toxic effects when taken in doses well above the recommended levels. It is very irritating on the stomach lining and the GI track in general. Even at doses less than life threatening, patients who overdose on this can have terrific stomachaches and occasionally GI bleeds. Salicylates, the chemical compound making up aspirin, have a direct effect on the breathing centers in the brain.

Patients hyperventilate, breathing much deeper and sometimes more rapidly than they need to. This results in decreased carbon dioxide levels in the blood which affects acid-base balance. There is an increase in metabolic rate often producing fever. Also, carbohydrate metabolism can be disrupted leading to severe cellular disruption. Blood coagulation can also be disrupted, which could understandably be ominous in the face of a stomach ulceration.

There is no specific treatment. Efforts are aimed at supportive measures. If the patient arrives at the emergency room soon enough, placing a tube into the stomach and irrigating can sometimes result in obtaining pill fragments. Activated charcoal is given in this and many overdoses to bind with the aspirin and excrete it. If the ingestion is severe enough, occasionally dialysis is necessary.

Acetaminophen is metabolized primarily by the liver and therefore most of its toxic effects are on the liver. When the liver's biochemical excretion is overcome, toxic metabolites build up within the liver and begin to cause damage and eventual necrosis to liver cells. If unchecked, liver failure can result. In true irreversible liver failure, only liver transplant is life saving.

There is a specific treatment for acetaminophen toxicity, but to use it, timing is crucial. Acetyl cysteine (Mucomyst) can replace overutilized liver metabolic pathways, and bind with acetaminophen before it performs its toxic activities. It must be instituted within the first twenty-four hours after the overdose, however, to be effective. After this, the damage to liver cells cannot be reversed. This is particularly frightening in those youths who are serious about suicide and don't tell anyone that they took the acetaminophen until two or three days after ingestion, when they finally start to feel very sick. By then very little can be done to reverse the already advanced liver damage.

Luckily, the teens I have seen recently with aspirin or acetaminophen overdoses have survived and done well, medically. Psychologically, long term recovery remains an open question. My job, however, is to keep these kids alive at least until they can get the help that they are crying out for. This can only be accomplished if the overdose is discovered early and effective treatment and support instituted as soon as possible.

John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. His column appears monthly in Pediatrics for Parents.