Acetaminophen (Paracetamol) Poisoning (T39.1X1A / T39.1X2A)
Lab
• Serum Acetaminophen Level (draw ≥4 hours after
single acute ingestion; repeat if indicated)
• CBC, BUN, Cr, electrolytes, LFTs, PT/INR, POCT Glucose
• ABG/VBG, Serum Lactate (massive overdose or hepatic failure)
• β-hCG (women of
childbearing age)
• Toxicology screen (co-ingestion suspected)
Investigation
• ECG (co-ingestion or altered mental status)
• Continuous Cardiac Monitor (massive overdose or unstable patient)
• Plot serum acetaminophen level on Rumack-Matthew Nomogram (single
acute ingestion with known time)
ER Treatment
GI Decontamination
• Activated Charcoal 1 g/kg (max 50 g) within 2 hours of
ingestion (up to 4 hours for massive ingestion or sustained-release
formulation if airway protected)
N-acetylcysteine (NAC)
• Start immediately if:
- Serum
acetaminophen level above treatment line on Rumack-Matthew Nomogram
- Unknown
time of ingestion
- Presentation
>8 hours after potentially toxic ingestion
- Delayed
laboratory result
- Repeated
supratherapeutic ingestion meeting treatment criteria
- Evidence
of hepatic injury regardless of serum level
IV NAC (Preferred)
• Two-bag regimen
- 200
mg/kg over 4 hr
- Then 100
mg/kg over 16 hr
- Total
= 300 mg/kg over 20 hr
Continue NAC beyond standard duration if
• Detectable acetaminophen concentration persists
• AST/ALT rising
• INR elevated
• Hepatic failure persists
Admission
• All patients receiving IV NAC
• Delayed presentation (>8 hr)
• Hepatotoxicity or acute liver failure
• Massive overdose (>30 g or >500 mg/kg)
• Altered mental status or co-ingestion requiring monitoring
• Psychiatric evaluation for intentional overdose
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