Acetaminophen Overdose: An Overview of Treatment

Stage I. (30 min - 24 hours)

• Sick (nausea/vomiting)
• Lethargic

Stage II. (24 - 72 hours)

• Liver pains (RUQ pain), increased LFTs, PT & T. bili

Stage III. (72 - 96 hours)

• Hepatic Encephalopathy
• Multi-system organ failure → Death
• Peaked LFTs
• Jaundice

Stage IV. (5 days - weeks)

• Recovery - good prognosis if patients make it this far

• PO vs IV (Adult) vs IV (Pediatrics)

PO

• Preparation:
  • Available in 10 and 20% solutions
  • Dilute to 5% solution
• Loading Dose:
  • 140 mg/kg
• Maintenance Dose:
  • 70 mg/kg q 4 hours x17 doses
• Duration:
  • 72 hours

IV (Adult)

• Preparation
  • Available in 20% solution
• Loading Dose:
  • 150 mg/kg in 200 mL D5W in H2O,
  • Infusion over 15-60 min
• Maintenance Dose:
  • 50 mg/kg in 500 mL D5W, Infusion over 4 hours
  • 100 mg/kg in 1000 mL D5W, Infusion over 16 hours
• Duration:
  • 20 hours

Ask: When was the time of ingestion?

•  This will guide your treatment algorithm

• <4 hours vs. between 4 - 24 hours  vs. >24 hours

Indications for “blind NAC” administration

• unknown time of ingestion

• >24 hours since time of ingestion

• results of of 1st APAP level is > 8 hours since time of ingestion

Indications for “full NAC” administration

• toxic nomogram

• unknown or >24 hours time of ingestion, 1st APAP > 10 ug/mL or AST/ALT increased