The Case for Improved Interprofessional Care: Fatal Analgesic Overdose Secondary to Acute Dental Pain during Pregnancy

Table 1

Summary of the patient’s course of illness.

	Date	Event
2 weeks before hospitalization		Patient obtains dental care. Her dental provider prescribed 20 tabs of Tylenol 3 for pain management. Patient takes 1-2 tabs/day but pain persists. She contacts her obstetrician who advises OTC acetaminophen for pain management. Patient obtains Extra Strength Tylenol (500 mg acetaminophen/tab) and takes 2-3 tabs, 10 times/day for last 10 days (20–30 tabs/day).
First hospitalization	Day 1	Patient presents to local emergency department (ED) for abdominal pain and nausea. Diagnosis of acute liver injury is assessed. N-Acetylcysteine (NAC) treatment is initiated.
	Day 2	Patient transferred to pediatric ICU and liver management continued via NAC protocol. Obstetrics and gynecology (ObGyn) team identifies live singleton fetus via ultrasound.
	Day 3	Undetectable fetal heart sounds or fetal movement by ObGyn. Fetal demise diagnosis is made.
	Day 4	Patient reports pain on mastication of right posterior dentition. Hospital dentistry (HD) consult is requested by patient’s care team.
	Day 5	HD consultation completed. Clinical examination reveals no indication for emergent interventional dental treatment. Palliative treatment is rendered via occlusal adjustment.
	Day 7	Wilson’s disease diagnosis made. The patient continues undergoing management of acute liver injury.
	Day 10	Delivery of nonviable fetus performed.
	Day 13	Patient reports “bubble on gum that popped” but is asymptomatic.; HD consultation completed and reveals tooth #30 (right mandibular molar) has draining sinus tract.
	Day 15	Pulpectomy performed on tooth #30 in hospital dental clinic. Dental needs for liver transplant clearance are assessed and scheduled for treatment on an outpatient basis.; Patient’s original dentist is contacted via telephone and relays that patient received dental treatment of 10 left posterior teeth, including root canal therapy on 3 molars in 1 visit.; Patient discharged from hospital.
6 days after hospitalization
Second hospitalization	Day 1	Patient presents to ED for worsening and persistent pelvic pain.; Patient admitted for management with Gastroenterology (GE) team and spontaneous bacterial peritonitis (SBP) treatment is initiated and paracentesis completed.
	Day 2	HD consultation for post-pulpectomy follow-up. Patient’s dental condition is stable and patient is scheduled for further dental management on an outpatient basis.
	Day 3	SBP treatment discontinued.
	Day 5	Patient discharged from hospital.
13 days after hospitalization	Day 3	Oral maxillofacial surgery (OMFS) consultation is completed for extractions under general anesthesia.
	Day 6	OMFS completes dental treatment under general anesthesia (teeth 1, 14, 16, 17, and 32 extracted).
Third hospitalization	Day 1	Patient presents to ED for abdominal pain, nausea, and diarrhea.; Patient admitted to adult ICU.
	Day 2	Patient’s condition deteriorates and patient is intubated.
	Day 3	Patient diagnosed with portal hypertensive gastropathy and ascites.; Continued management of liver complications including paracentesis and esophagogastroduodenoscopy (diagnostic endoscopic procedure for visualization of upper portion of GI tract).
	Day 5	Patient’s condition stabilizes and patient is extubated.
	Day 9	Paracentesis completed with 4 L of fluid removal.
	Day 10	Patient has an episode of unresponsiveness to sternal rub, requiring 1.2 IV Narcan administration before patient’s mental status returns. This incident is attributed to Phenergan sedation.
	Day 17	Patient discharged from hospital.
6 days after hospitalization
Fourth hospitalization	Day 1	Patient admitted to local ED after found unresponsive at home.; Patient transferred to adult ICU and is intubated.; Patient diagnosed for septic shock secondary to SBP.
	Day 3	Patient diagnosed for cardiac ischemia with development of nonsustained ventricular tachycardia. Multiorgan failure is observed.; Patient shows intermittent prolonged unstable arrhythmia with ventricular fibrillation and hypotension.; Patient’s care team discusses poor prognosis with family.
	Day 4	Patient dies.