What are the guideline sources, guidelines and references for Acetaminophen poisoning ?
Guideline sources The following summarized guidelines for the evaluation and management of acetaminophen poisoning are prepared by our editorial team based on guidelines from the American Association for the Study of Liver Diseases (AASLD 2022), the Treatment of Paracetamol Poisoning Writing Group (TPPWG 2020), the Extracorporeal Treatments in Poisoning Workgroup (EXTRIP 2014), and the American Association of Poison Control Centers (AAPCC 2006). 1 2 3 4 Calculator King's College Criteria for aceta Guidelines https://web.pathway.md/diseases/recy8dq98BY2MASYn 1/5 6/23/23, 1:27 AM Acetaminophen poisoning Pathway 1. Screening and diagnosis Diagnosis: As per AASLD 2022 guidelines, recognize that acetaminophen is a dose-dependent hepatotoxin causing acute pericentral liver injury when doses of > 4 g are ingested within a 24-hour period or excessive doses over several days. E Show 2 more As per AAPCC 2006 guidelines, set > 4 g or 100 mg/kg (whichever is less) per day of acetaminophen as repeated supratherapeutic ingestion of acetaminophen in patients with conditions purported to increase susceptibility to acetaminophen toxicity (AUD, isoniazid use, prolonged fasting). B 2. Classification and risk stratification Prognosis: recognize that the prognosis in acetaminophen-related ALF is related to the degree of encephalopathy, coagulopathy, and acidosis. E 3. Diagnostic investigations History of ingestion: elicit history including the patient's age and intent, B specific formulation and dose of acetaminophen, ingestion pattern, duration of ingestion, B and concomitant medications ingested. B 4. Medical management Setting of care: refer patients with stated or suspected self-harm or recipients of a potentially malicious administration of acetaminophen to an emergency department regardless of the amount ingested. B Show 7 more N-acetylcysteine: As per AASLD 2022 guidelines, administer IV or PO N-acetylcysteine to prevent liver injury, nearly completely if administered within 12 hours of acetaminophen ingestion. E As per TPPWG 2020 guidelines, administer N-acetylcysteine as a two-bag regimen (200 mg/kg over 4 hours followed by 100 mg/kg over 16 hours). B Show 8 more Cimetidine: do not use cimetidine as an antidote in patients with acetaminophen poisoning. D 5. Nonpharmacologic interventions Gastrointestinal decontamination: https://web.pathway.md/diseases/recy8dq98BY2MASYn 2/5 6/23/23, 1:27 AM Acetaminophen poisoning Pathway As per AASLD 2022 guidelines, perform gastric lavage and administer activated charcoal in all patients presenting within 4 hours of a single-time-point acetaminophen overdose. E As per TPPWG 2020 guidelines, administer activated charcoal 50 g in cooperative, awake adult patients presenting within 2 hours of ingestion of a toxic dose of immediate-release acetaminophen, or within 4 hours of immediate-release acetaminophen overdoses > 30 g. B As per AAPCC 2006 guidelines: Consider administering activated charcoal if local poison center policies support its prehospital use, a toxic dose of acetaminophen has been taken, and fewer than 2 hours have elapsed since the ingestion. B Do not perform gastrointestinal decontamination in patients with repeated supratherapeutic ingestion of acetaminophen. D 6. Therapeutic procedures Extracorporeal treatment: Consider initiating ECTR in patients with any of the following: acetaminophen concentration > 1,000 mg/L (1D) or > 800 mg/L, if N-acetylcysteine is not administered acetaminophen concentration > 700 mg/L (1D) or > 500 mg/L, (2D) presenting with altered mental status, metabolic acidosis, elevated lactate, if N-acetylcysteine is not administered acetaminophen concentration > 900 mg/L (1D) or > 800 mg/L, (2D) presenting with altered mental status, metabolic acidosis, elevated lactate, if N-acetylcysteine is administered. C Show 4 more 7. Surgical interventions Liver transplantation: Consult a liver transplant unit if any of the following criteria are met: INR > 3.0 at 48 hours or > 4.5 at any time oliguria or creatinine > 200 mcmol/L persistent acidosis (pH < 7.3) or arterial lactate > 3 mmol/L systolic hypotension with BP < 80 mmHg, despite resuscitation hypoglycemia, severe thrombocytopenia, or encephalopathy of any degree any alteration of consciousness (GCS < 15) not associated with sedative co-ingestions. E Do not administer clotting factors unless the patient is bleeding or after discussion with a liver transplant unit. D 8. Specific circumstances Pediatric patients: https://web.pathway.md/diseases/recy8dq98BY2MASYn 3/5 6/23/23, 1:27 AM Acetaminophen poisoning Pathway As per TPPWG 2020 guidelines, measure serum acetaminophen concentration at least 2 hours after ingestion in < 6 years old pediatric patients with suspected ingestion of > 200 mg/kg of liquid acetaminophen. Do not administer N-acetylcysteine if the 2-4-hour acetaminophen concentration is < 150 mg/L. Repeat measurement of acetaminophen concentration 4 hours after ingestion if the 2-hour acetaminophen concentration is > 150 mg/L and administer N- acetylcysteine if the 4-hour concentration is 150 mg/L. B Show 2 more As per AAPCC 2006 guidelines, refer < 6 years old pediatric patients to an emergency department if the estimated acute ingestion amount is unknown or is 200 mg/kg. Consider monitoring patients at home if the dose ingested is < 200 mg/kg. B Show 3 more 9. Follow-up and surveillance Indications for poison center consultation: Consult a poisons information center in the following situations: very large overdoses - immediate-release or modified-release acetaminophen overdoses of 50 g or 1 g/kg (whichever is less) high acetaminophen concentration, more than triple the nomogram line IV acetaminophen errors or overdoses, as the treatment threshold is lower patients with hepatotoxicity (ALT > 1,000 IU/L) neonatal acetaminophen poisonings. E Assessment of treatment response: measure ALT levels near the completion of N-acetylcysteine (2 hours before completion of the infusion) in all patients. Measure acetaminophen concentration in patients with an initial acetaminophen level > 2 the nomogram line. Continue N-acetylcysteine if the acetaminophen concentration is > 10 mg/L or ALT is elevated (> 50 U/L) and increasing (if baseline ALT > 50 U/L). Repeat ALT measurement in all cases as there is a small (< 1%) risk of developing acute liver injury despite treatment with acetylcysteine within 8 hours. B Show 3 more References 1. Richard C Dart, Andrew R Erdman, Kent R Olson et al. Acetaminophen poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol Phila). 2006;44 1 1 18. Open 2. Robert J Fontana, Iris Liou, Adrian Reuben et al. AASLD practice guidance on drug, herbal, and dietary supplement-induced liver injury. Hepatology. 2022 Jul 27. Open 3. S Gosselin, D N Juurlink, J T Kielstein et al. Extracorporeal treatment for acetaminophen poisoning: recommendations from the EXTRIP workgroup. Clin Toxicol Phila). Sep-Oct 2014;52 8 856 67. Open 4. Angela L Chiew, David Reith, Adam Pomerleau et al. Updated guidelines for the management of paracetamol poisoning in Australia and New Zealand. Med J Aust. 2020 Mar;212 4 175 183. Open https://web.pathway.md/diseases/recy8dq98BY2MASYn 4/5 6/23/23, 1:27 AM Acetaminophen poisoning Pathway 5. McNeil Consumer Healthcare. Guidelines for the Management of Acetaminophen Overdose. McNeil Consumer Healthcare. 2018 Sep 8. Open 6. No authors listed. NCPDP recommendations for dose accumulation monitoring in the inpatient setting: Acetaminophen case model, version 1.0. Am J Health Syst Pharm. 2016 Aug 1;73 15 1144 65. Open 7. J G O'Grady, G J Alexander, K M Hayllar et al. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology. 1989 Aug;97 2 439 45. Open https://web.pathway.md/diseases/recy8dq98BY2MASYn 5/5