Management ABCs O2 and fluids as necessary Cardiac monitor (coingestions) Activated Charcoal – 1g/kg up to 50 g PO within 4 hrs of ingestion N-acetylcysteine (NAC) Indications Serum APAP concentration above tx line on nomogram (Fig. 1) Single APAP ingestion > 150 mg/kg or 7.5 g total in a patient for whom we can’t obtain an APAP concentration until >8 hrs Patient with unknown time of ingestion and serum APAP > 10mcg/mL Patient with hx APAP ingestion and ANY evidence of liver injury Patients who present > 24 hrs post-ingestion with lab signs of liver injury PEARL – the nomogram is the most important way to determine the need for NAC therapy in an acute APAP OD 72-hour PO protocol – loading dose 140 mg/kg PO, then 70 mg/kg PO every 4 hrs for 17 total doses 21-hour IV protocol – loading dose 150 mg/kg over 1 hr, then 4-hr infusion of 12.5mg/kg/hr, then 16-hr infusion at 6.25 mg/kg/hr PEARL – NAC is safe and effective in pregnant women. Crosses the placenta and thus IV form preferred. Disposition Patient treated with NACadmitted Patient asymptomatic/mild symptomsadmit to medicine or obs unit Patient had evidence severe heaptotoxicity/hepatic failureadmit to medical ICU PEARL – consult a medical toxicologist/regional poison control center as needed and obtain a psychiatric consult for intentional overdoses (Contact: ) Figure 1 http://www.mdcalc.com/acetaminophen-overdose-and-iv-nac-dosing/
Management ABCs O2 and fluids as necessary Cardiac monitor (coingestions) Activated Charcoal – 1g/kg up to 50 g PO within 4 hrs of ingestion N-acetylcysteine (NAC) Indications Serum APAP concentration above tx line on nomogram (Fig. 1) Single APAP ingestion > 150 mg/kg or 7.5 g total in a patient for whom we can’t obtain an APAP concentration until >8 hrs Patient with unknown time of ingestion and serum APAP > 10mcg/mL Patient with hx APAP ingestion and ANY evidence of liver injury Patients who present > 24 hrs post-ingestion with lab signs of liver injury PEARL – the nomogram is the most important way to determine the need for NAC therapy in an acute APAP OD 72-hour PO protocol – loading dose 140 mg/kg PO, then 70 mg/kg PO every 4 hrs for 17 total doses 21-hour IV protocol – loading dose 150 mg/kg over 1 hr, then 4-hr infusion of 12.5mg/kg/hr, then 16-hr infusion at 6.25 mg/kg/hr PEARL – NAC is safe and effective in pregnant women. Crosses the placenta and thus IV form preferred. Disposition Patient treated with NACadmitted Patient asymptomatic/mild symptomsadmit to medicine or obs unit Patient had evidence severe heaptotoxicity/hepatic failureadmit to medical ICU PEARL – consult a medical toxicologist/regional poison control center as needed and obtain a psychiatric consult for intentional overdoses (Contact: ) Figure 1 http://www.mdcalc.com/acetaminophen-overdose-and-iv-nac-dosing/