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:

Rumack-Matthew Nomogram (MDCalc)