Paracetamol overdose: management

Paracetamol overdose: management

The following is based on the National Poisons Information Service(NPIS)/TOXBASE database of paracetamol overdose management. The big change in these guidelines was the removal of the 'high-risk' treatment line on the normogram. All patients are therefore treated the same regardless of risk factors for hepatotoxicity.

The NPIS/TOXBASE should always be consulted for situations outside of the normal parameters.

• this includes overdoses from IV paracetamol
  overdoses from IV paracetamol
  You've never been tested on this concept
  You've not yet rated this concept.
  , where advice from NPIS should always be sought

The minority of patients who present within 1 hour may benefit from activated charcoal to reduce absorption of the drug

present within 1 hour may benefit from activated charcoal to reduce absorption of the drug

You've never been tested on this concept

You've not yet rated this concept.

.

Acetylcysteine should be given if:

• the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours, 15 mg/L at 15 hours and 3.13 mg/L at 24 hours, regardless of risk factors of hepatotoxicity
• there is a staggered overdose
  Patients who take a staggered paracetamol overdose should receive treatment with acetylcysteine
  You've never been tested on this concept
  You've not yet rated this concept.
  Importance: 84
  or there is doubt over the time of paracetamol ingestion
  • an overdose is considered staggered if all the tablets were not taken within 1 hour
  • acetylcysteine can later be discontinued
    For a staggered paracetamol overdose, acetylcysteine can later be discontinued if, after at least 4 hours since last ingestion, the patient is - asymptomatic - and paracetamol is < 10 mg/L - and ALT normal - and INR ≤ 1.3
    You've never been tested on this concept
    You've not yet rated this concept.
    Importance: 81
    if, after at least 4 hours since last ingestion, the patient is asymptomatic, paracetamol is < 10 mg/L, ALT normal, and INR ≤ 1.3
• patients presenting 8–24 hours
  patients presenting 8–24 hours
  You've never been tested on this concept
  You've not yet rated this concept.
  after an acute overdose if:
  • dose is >150 mg/kg, or
  • the amount ingested is unknown, or
  • the patient is symptomatic with jaundice or hepatic tenderness
• patients who present > 24 hours
  patients who present > 24 hours
  You've never been tested on this concept
  You've not yet rated this concept.
  if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal
  • acetylcysteine should be continued if the paracetamol concentration or ALT remains elevated
    Paracetamol overdose: if presentation > 24 hours: acetylcysteine should be continued if the paracetamol concentration or ALT remains elevated whilst seeking specialist advice
    You've never been tested on this concept
    You've not yet rated this concept.
    Importance: 96
    whilst seeking specialist advice

Acetylcysteine is now infused over 1 hour (rather than the previous 15 minutes) to reduce the number of adverse effects. Acetylcysteine commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release)

Acetylcysteine commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release)

You've never been tested on this concept

You've not yet rated this concept.

. Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate

Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate

You've never been tested on this concept

You've not yet rated this concept.

.

+PassMedicine Notes

The following is based on the National Poisons Information Service(NPIS)/TOXBASE database of paracetamol overdose management. The big change in these guidelines was the removal of the 'high-risk' treatment line on the normogram. All patients are therefore treated the same regardless of risk factors for hepatotoxicity.

The NPIS/TOXBASE should always be consulted for situations outside of the normal parameters.

• this includes overdoses from IV paracetamol, where advice from NPIS should always be sought

The minority of patients who present within 1 hour may benefit from activated charcoal to reduce absorption of the drug.

Acetylcysteine should be given if:

• the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours, 15 mg/L at 15 hours and 3.13 mg/L at 24 hours, regardless of risk factors of hepatotoxicity
• there is a staggered overdose or there is doubt over the time of paracetamol ingestion
• an overdose is considered staggered if all the tablets were not taken within 1 hour
• acetylcysteine can later be discontinued if, after at least 4 hours since last ingestion, the patient is asymptomatic, paracetamol is < 10 mg/L, ALT normal, and INR ≤ 1.3
• patients presenting 8–24 hours after an acute overdose if:
• dose is >150 mg/kg, or
• the amount ingested is unknown, or
• the patient is symptomatic with jaundice or hepatic tenderness
• patients who present > 24 hours if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal
• acetylcysteine should be continued if the paracetamol concentration or ALT remains elevated whilst seeking specialist advice

Acetylcysteine is now infused over 1 hour (rather than the previous 15 minutes) to reduce the number of adverse effects. Acetylcysteine commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release). Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate.

pdd021.png#

King's College Hospital criteria for liver transplantation (paracetamol liver failure)

Arterial pH < 7.3, 24 hours after ingestion

or all of the following:

• prothrombin time > 100 seconds
• creatinine > 300 µmol/l
• grade III or IV encephalopathy|