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Acetaminophen Overdose & Toxicology Pearls
- History: Figure out how much was taken, what time the ingestion occurred, and if any other toxins were ingested
- Physical Exam: Perform a regular physical exam, and in addition, perform the toxicologic physical exam!
- Check pupil size
- Assess neuromuscular status for rigidity/clonus
- Perform the “toxicologist handshake”
- Listen to bowel sounds
- Workup:
- Accucheck
- ECG
- CBC, CMP, VBG
- Acetaminophen Level (now and at four hours); Salicylate Level
- UDS
- Consider specific drug levels (eg digoxin, lithium, valproic acid, etc) ; consider ammonia level for valproic acid OD
- Management:
- ABCs first
- Consider decontamination (remove clothes, hose down with water if chemical exposure, consider activated charcoal or gastric lavage for early ingestions)
- Consult poison control/toxicology
- Consult psychiatry if it was an attempt at self harm
- Administer NAC if considered to be a “toxic ingestion of acetaminophen”
- Definition of an “Acetaminophen Toxic Ingestion”
- Single ingestion of acetaminophen greater than 150mg/kg
- Data point on Rumack-Matthew Nomogram that is above the treatment line
- If UNKNOWN amount / UNKNOWN timing of ingestion, treat if LFTs are elevated or if serum acetaminophen level is above normal limits
- Rule of 150
- Toxic Ingestion is considered to be a single ingestion greater than 150mg/kg
- Toxic Ingestion is considered to be if the acetaminophen level at the four hour mark is >150ug/mL (this would be above the treatment line on the Rumack-Matthew Nomogrom)
- Dose of NAC is 150mg/kg IV
Further Reading: