Acetaminophen Poisoning: A Case Based Approach

Overview

Journal J Acute Med

Date 2020 Sep 30

PMID 32995209

Authors

Kennon Heard

Affiliations

Soon will be listed here.

Abstract

Emergency and critical care physicians commonly evaluate and treat patients poisoned by acetaminophen. While the basics of management were established in the 1970s, over the past 20 years we have recognized subtleties and variations in presentations that alter the approach to evaluation and treatment. In this paper I will present several cases that illustrate some of the most common variations in presentations of acetaminophen poisoning and offer recommendations for modifi cations of testing and treatment based on several recent studies.

References

Schwartz E, Hayes B, Sarmiento K . Development of hepatic failure despite use of intravenous acetylcysteine after a massive ingestion of acetaminophen and diphenhydramine. Ann Emerg Med. 2008; 54(3):421-3. DOI: 10.1016/j.annemergmed.2008.10.001. View

Mohler C, Nordt S, Williams S, Manoguerra A, Clark R . Prospective evaluation of mild to moderate pediatric acetaminophen exposures. Ann Emerg Med. 2000; 35(3):239-44. DOI: 10.1016/s0196-0644(00)70074-6. View

Chiew A, Isbister G, Kirby K, Page C, Chan B, Buckley N . Massive paracetamol overdose: an observational study of the effect of activated charcoal and increased acetylcysteine dose (ATOM-2). Clin Toxicol (Phila). 2017; 55(10):1055-1065. DOI: 10.1080/15563650.2017.1334915. View

Woodhead J, Howell B, Yang Y, Harrill A, Clewell 3rd H, Andersen M . An analysis of N-acetylcysteine treatment for acetaminophen overdose using a systems model of drug-induced liver injury. J Pharmacol Exp Ther. 2012; 342(2):529-40. DOI: 10.1124/jpet.112.192930. View

OGrady J, Alexander G, Hayllar K, Williams R . Early indicators of prognosis in fulminant hepatic failure. Gastroenterology. 1989; 97(2):439-45. DOI: 10.1016/0016-5085(89)90081-4. View

Heard K, Rumack B, Green J, Bucher-Bartelson B, Heard S, Bronstein A . A single-arm clinical trial of a 48-hour intravenous N-acetylcysteine protocol for treatment of acetaminophen poisoning. Clin Toxicol (Phila). 2014; 52(5):512-8. DOI: 10.3109/15563650.2014.902955. View

Thummel K, Slattery J, Ro H, Chien J, Nelson S, Lown K . Ethanol and production of the hepatotoxic metabolite of acetaminophen in healthy adults. Clin Pharmacol Ther. 2000; 67(6):591-9. DOI: 10.1067/mcp.2000.106574. View

Marks D, Dargan P, Archer J, Davies C, Dines A, Wood D . Outcomes from massive paracetamol overdose: a retrospective observational study. Br J Clin Pharmacol. 2016; 83(6):1263-1272. PMC: 5427245. DOI: 10.1111/bcp.13214. View

Gosselin S, Juurlink D, Kielstein J, Ghannoum M, Lavergne V, Nolin T . Extracorporeal treatment for acetaminophen poisoning: recommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2014; 52(8):856-67. DOI: 10.3109/15563650.2014.946994. View

10.

Brass E, Reynolds K, Burnham R, Green J . Frequency of Poison Center Exposures for Pediatric Accidental Unsupervised Ingestions of Acetaminophen after the Introduction of Flow Restrictors. J Pediatr. 2018; 198:254-259.e1. DOI: 10.1016/j.jpeds.2018.02.033. View

11.

Prescott L . Paracetamol, alcohol and the liver. Br J Clin Pharmacol. 2000; 49(4):291-301. PMC: 2014937. DOI: 10.1046/j.1365-2125.2000.00167.x. View

12.

Sandilands E, Bateman D . Adverse reactions associated with acetylcysteine. Clin Toxicol (Phila). 2009; 47(2):81-8. DOI: 10.1080/15563650802665587. View

13.

Smilkstein M, Bronstein A, Linden C, Augenstein W, Kulig K, Rumack B . Acetaminophen overdose: a 48-hour intravenous N-acetylcysteine treatment protocol. Ann Emerg Med. 1991; 20(10):1058-63. DOI: 10.1016/s0196-0644(05)81352-6. View

14.

Larson A, Polson J, Fontana R, Davern T, Lalani E, Hynan L . Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study. Hepatology. 2005; 42(6):1364-72. DOI: 10.1002/hep.20948. View

15.

Keays R, Harrison P, Wendon J, Forbes A, Gove C, Alexander G . Intravenous acetylcysteine in paracetamol induced fulminant hepatic failure: a prospective controlled trial. BMJ. 1991; 303(6809):1026-9. PMC: 1671790. DOI: 10.1136/bmj.303.6809.1026. View

16.

Johnson M, McCammon C, Mullins M, Halcomb S . Evaluation of a simplified N-acetylcysteine dosing regimen for the treatment of acetaminophen toxicity. Ann Pharmacother. 2011; 45(6):713-20. DOI: 10.1345/aph.1P613. View

17.

Isbister G, Downes M, Mcnamara K, Berling I, Whyte I, Page C . A prospective observational study of a novel 2-phase infusion protocol for the administration of acetylcysteine in paracetamol poisoning. Clin Toxicol (Phila). 2015; 54(2):120-6. DOI: 10.3109/15563650.2015.1115057. View

18.

Cairney D, Beckwith H, Al-Hourani K, Eddleston M, Bateman D, Dear J . Plasma paracetamol concentration at hospital presentation has a dose-dependent relationship with liver injury despite prompt treatment with intravenous acetylcysteine. Clin Toxicol (Phila). 2016; 54(5):405-10. DOI: 10.3109/15563650.2016.1159309. View

19.

Bateman D, Dear J, Thanacoody H, Thomas S, Eddleston M, Sandilands E . Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomised controlled trial. Lancet. 2013; 383(9918):697-704. DOI: 10.1016/S0140-6736(13)62062-0. View

20.

Rumack B . Acetaminophen hepatotoxicity: the first 35 years. J Toxicol Clin Toxicol. 2002; 40(1):3-20. DOI: 10.1081/clt-120002882. View