What is the best course of action for a patient who has taken an overdose of 10 grams (50 x 200mg) of ibuprofen (nonsteroidal anti-inflammatory drug (NSAID)) and is experiencing recurrent nausea and inability to hold food down?

Management of Ibuprofen Overdose with Persistent Nausea

This patient requires immediate emergency department evaluation with aggressive supportive care, including intravenous fluid resuscitation, gastrointestinal decontamination if within appropriate timeframe, serial monitoring of renal function and acid-base status, and antiemetic therapy to control nausea. 1

Immediate Emergency Department Referral Required

This 10-gram ibuprofen ingestion (50 × 200mg tablets) constitutes a massive overdose that can cause life-threatening complications:

• Serious toxicity occurs with ingestions >400 mg/kg in children and large ingestions in adults, with documented cases of coma, metabolic acidosis, acute renal failure, and adult respiratory distress syndrome 2, 3, 4
• Serum ibuprofen levels >700 mg/L have been associated with severe toxicity including altered mental status and metabolic derangements, though survival is possible with aggressive supportive care 3
• The FDA warns that ibuprofen overdose can cause serious gastrointestinal bleeding, ulceration, and perforation without warning symptoms, which may be fatal 1

Critical Initial Assessment in the Emergency Department

Upon arrival, the following must be evaluated immediately:

• Mental status and airway protection capability, as coma can develop hours after ingestion and may require intubation 3, 4
• Vital signs including blood pressure and heart rate, as shock has been documented in severe ibuprofen overdose 4
• Serum creatinine and renal function, as acute renal insufficiency can develop within 11-27 hours post-ingestion even in previously healthy patients 5
• Arterial or venous blood gas for metabolic acidosis, which is a hallmark of severe ibuprofen toxicity 2, 3, 4
• Electrolyte panel, as metabolic derangements contribute to toxicity 2

Gastrointestinal Decontamination Strategy

Activated charcoal should be administered if the patient presents within 1-2 hours of ingestion and can protect their airway (or after intubation if mental status is compromised) 4:

• The recurrent nausea and vomiting in this case may actually represent ongoing gastric irritation from residual ibuprofen
• Do NOT induce vomiting, as this increases aspiration risk and does not improve outcomes 1
• If the patient cannot tolerate oral activated charcoal due to vomiting, nasogastric tube placement after airway protection may be necessary 4

Aggressive Fluid Resuscitation

Intravenous crystalloid fluid resuscitation is the cornerstone of management to prevent or treat shock and support renal perfusion 4:

• Fluid resuscitation helps prevent acute renal failure, which occurs due to prostaglandin-mediated reduction in renal blood flow 1, 5
• Monitor urine output closely, as both oliguria (renal failure) and polyuria (rarely described but documented) can occur 3, 5
• Maintain adequate hydration to support the kidneys' ability to eliminate ibuprofen 5

Antiemetic Management for Persistent Nausea

For the recurrent nausea preventing oral intake:

• Ondansetron 4-8 mg IV is first-line for acute nausea in the overdose setting, as it does not worsen mental status 6, 7
• Metoclopramide 10-20 mg IV can be added if ondansetron alone is insufficient, providing both antiemetic and prokinetic effects 6, 7
• Avoid using oral antiemetics initially given the patient's inability to hold food down; intravenous or intramuscular routes are required 6
• Consider adding dexamethasone 4-10 mg IV for refractory nausea, which enhances antiemetic efficacy through corticosteroid mechanisms 6, 7

Serial Monitoring Requirements

The following must be monitored serially over 24-72 hours:

• Serum creatinine every 6-12 hours for at least 72 hours, as renal function may not normalize until this timeframe 5
• Repeat blood gas or venous CO2 to monitor for development or resolution of metabolic acidosis 2, 3
• Mental status assessments, as deterioration can occur hours after initial presentation 3, 4
• Urinalysis for hematuria, which may indicate renal injury 5

Specific Pitfalls to Avoid

• Do NOT assume the patient is stable based on initial presentation alone, as serious toxicity including coma and metabolic acidosis can develop 7+ hours post-ingestion 3, 4
• Do NOT discharge the patient from the emergency department without extended observation, as complications are delayed and unpredictable 2, 3
• Do NOT use NSAIDs or aspirin for any concurrent pain, as this compounds gastrointestinal and renal toxicity 6, 1
• Do NOT rely on gastric acid suppression alone (proton pump inhibitors or H2 blockers) to manage nausea, as this does not address the underlying toxicity 6

Disposition and Ongoing Care

Hospital admission for at least 24-48 hours of observation is mandatory given the massive ingestion and presence of symptoms 2, 3, 4:

• Patients with normal renal function, no metabolic acidosis, and resolution of symptoms by 24-48 hours can typically be discharged 5, 8
• Most patients survive with aggressive supportive care alone, even with extremely high serum levels, if complications are recognized and managed early 3, 8
• Psychiatric evaluation should be arranged before discharge if this was an intentional ingestion 8