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Acetaminophen Toxicity


35 yo M presents with witnessed episode of tyelenol overdose at 9 45 PM. Patient reportedly took 325 mg, 25 tablets. Is seen in the ER 1 hr later at 10 45 PM. Labs include the following over time. First one was reported at 0006 AM. 
  • Time line represents the value at 
    • 3 hr: 316
    • 5 hr: 247
    • 7 hr : 273
    • 17 hr : 51
    • 29 hr: < 10




How should this patient be managed? 

Lets first review the Rumack Matthew nomogram. 


Since, patient has presented at 1 hr, treatment should be instituted immediately. 

What is the treatment? 
  • Oral Charcoal : 50 gm to all patients presenting within 4 hr of ingestion unless contraindicated 
    • This patient was not given due to risk of vomiting. 
  • N- Acetyl Cysteine (NAC) 
    • Oral: Non-pregnant, Functoinal GI tract, No evidence of Hepatic Toxicity 
      • Loading dose 140 mg / kg followed by  70 mg / kg every 4 hr for total 17 dose 
      • If vomitting occurs, repeat the dose immediately as possible
      • Can be stopped 24-36 hr after ingestion if acetaminophen level is < 10 with no signs of hepatotoxicity
    • IV
      • No hepatotoxityc: INR < 2: 21 hr IV protocol; 150 mg / kg loading dose over 60 min followed by 50 mg / kg infused over 4 hr, then 100 mg / kg infused over the 16 hr (Total: 1 hr + 4 hr + 16 hr = 21 hr)
      • Hepatoxiicty: INR > 2: 21 hr protocol + followed by continous IV infusion at 6.25 mg / kg / hr until INR is < 2
For our patient, we can start oral NAC with oral Charcoal and be stopped at 29 hr once acetaminophen level is < 10







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