Toxicology/clinical policyClinical Policy: Critical Issues in the Management of Patients Presenting to the Emergency Department With Acetaminophen Overdose
Section snippets
Abstract
This clinical policy focuses on critical issues concerning the management of patients presenting to the emergency department (ED) with acetaminophen overdose. The subcommittee reviewed the medical literature relevant to the questions posed. The critical questions are:
- 1
What are the indications for N-acetylcysteine (NAC) in the acetaminophen overdose patient with a known time of acute ingestion who can be risk stratified by the Rumack-Matthew nomogram?
- 2
What are the indications for NAC in the
Methodology
This clinical policy was created after careful review and critical analysis of the medical literature. MEDLINE searches for articles published between January 1974 and January 2006 were performed using a combination of key words and their variations, including “acetaminophen,” “paracetamol,” “APAP,” “extended release,” “acetylcysteine,” “N-acetylcysteine,” “Mucomyst,” “NAC,” “liver disease,” “aminotransferase,” “aspartate transaminase,” “alanine transferase,” “SGOT,” “AST,” “ALT,” and
Critical Questions
- 1
What are the indications for NAC in the acetaminophen overdose patient with a known time of acute ingestion who can be risk stratified by the Rumack-Matthew nomogram?
References (55)
- et al.
Acetaminophen overdose: a 48-hour intravenous N-acetylcysteine treatment protocol
Ann Emerg Med.
(1991) - et al.
Efficacy of oral versus intravenous N-acetylcysteine in acetaminophen overdose: results of an open-label clinical trial
J Pediatr.
(1998) - et al.
Shorter duration of oral N-acetylcysteine therapy for acute acetaminophen overdose
Ann Emerg Med.
(2000) - et al.
A prospective evaluation of the effect of activated charcoal before oral N-acetylcysteine in acetaminophen overdose
Ann Emerg Med.
(1994) - et al.
Management of anaphylactoid reactions to intravenous N-acetylcysteine
Ann Emerg Med.
(1998) - et al.
The Australasian Clinical Toxicology Investigators Collaboration randomized trial of different loading infusion rates of N-acetylcysteine
Ann Emerg Med.
(2005) - et al.
Prospective evaluation of repeated supratherapeutic acetaminophen (paracetamol) ingestion
Ann Emerg Med.
(2004) - et al.
The origins, benefits, harms, and implications of emergency medicine clinical policies
Ann Emerg Med.
(1993) - et al.
Treatment of paracetamol (acetaminophen) poisoning with N-acetylcysteine
Lancet
(1977) - et al.
Improved outcome of paracetamol-induced fulminant hepatic failure by late administration of acetylcysteine
Lancet
(1990)
Late increase in acetaminophen concentration after overdose of Tylenol Extended Relief
Ann Emerg Med.
Severe hepatic damage after acetaminophen use in psittacosis
Am J Med.
Chronic acetaminophen toxicity: a case report and review of the literature
J Emerg Med.
Acetaminophen associated hepatic injury, report of two cases showing unusual portal tract reactions
Hum Pathol.
Acetaminophen poisoning: a case report of the use of acetylcysteine
Am J Hosp Pharm.
Oral or intravenous N-acetylcysteine: which is the treatment of choice for acetaminophen (paracetamol) poisoning?
J Toxicol Clin Toxicol.
The intravenous use of oral acetylcysteine (mucomyst) for the treatment of acetaminophen overdose
Arch Intern Med.
A 20-hour treatment for acute acetaminophen overdose
N Engl J Med.
Comparison of oral and i.v. acetylcysteine in the treatment of acetaminophen poisoning
Am J Health Syst Pharm.
The use of ondansetron in the treatment of nausea and vomiting associated with acetaminophen poisoning
J Toxicol Clin Toxicol.
Use of ondansetron and other antiemetics in the management of toxic acetaminophen ingestions
J Toxicol Clin Toxicol.
Effect of metoclopramide dose on preventing emesis after oral administration of N-acetylcysteine for acetaminophen overdose
J Toxicol Clin Toxicol.
Fatal anaphylactoid reaction to N-acetylcysteine: caution in patients with asthma
Emerg Med J.
Acetaminophen poisoning and toxicity
Pediatrics
Acetaminophen overdose: 662 cases with evaluation of oral acetylcysteine treatment
Arch Intern Med.
Acetaminophen poisoning: an evidence-based consensus guideline for out-of-hospital management
Clin Tox.
Acetaminophen toxicity in an urban county hospital
N Engl J Med.
Cited by (34)
Acetaminophen is Undetectable in Plasma From More Than Half of Patients Believed to Have Acute Liver Failure Due to Overdose
2019, Clinical Gastroenterology and HepatologyCitation Excerpt :The percentage of patients in whom APAP levels had become undetectable was comparable between the ALF and ALI groups. Clinical experience has shown that the original Rumack nomogram is not applicable to many patients with toxic APAP ingestion, particularly those who present when the liver injury has already been initiated (usually >24 hours after ingestion) or in those with multiple time point ingestions (sometimes called unintentional or staggered).10 Because our study only includes those admitted to hospital with signs and symptoms of ALI/ALF, this is not a surprising result, although it challenges in part the use of APAP levels to determine etiology in this setting.
Expert Consensus Guidelines for Stocking of Antidotes in Hospitals That Provide Emergency Care
2018, Annals of Emergency MedicineNew potential biomarkers of acetaminophen-induced hepatotoxicity
2016, Advances in Medical SciencesThe use of thymoquinone in nephrotoxicity related to acetaminophen
2015, International Journal of SurgeryCitation Excerpt :Acetaminophen (APAP) overdose is one of the most commonly reported types of toxic ingestion, worldwide; in 2005 over 165,000 cases of acetaminophen overdose were reported in the United States alone [1]. When ingested, high doses of APAP and its metabolites cause toxicity in both the liver and extra hepatic tissues [2,3]. APAP hepatotoxicity is a well-known and extensively studied clinical phenomenon, although renal insufficiency occurs in approximately 1–2% of patients with APAP overdose [4].
Antipyretic poisoning
2011, Emergency Medicine SecretsA review of the literature on the effects of acetaminophen on pregnancy outcome
2010, Reproductive ToxicologyCitation Excerpt :Overdose is characterized by a plasma acetaminophen concentration of ≥150 mg/L at 4 h after ingestion, the concentration at which specific treatment to prevent hepatotoxicity is indicated [38]. Using cases referred to a Teratology Information Service (TIS) in collaboration with the London National Poisons Information Services, McElhatton et al. conducted a prospective study to investigate the outcome of pregnancy in 300 women who had self-administered an acetaminophen overdose between 1984 and 1992 [39]. This study was an expanded follow-up of a previous review of 115 cases [40].