Emergency Notes

Chronic ingestion

• In 2004, Daly et al demonstrated that patients with delayed presentations (more than 24 hours after ingestion) or chronic ingestions who had an acetaminophen level of less than 10 mcg/mL and an AST below 50 IU/mL had a 0% risk of developing hepatotoxicity
  
• detectable serum acetaminophen levels (>10 mcg/mL) or elevated liver enzymes should be presumed to have acetaminophen toxicity.
• all patients with delayed presentations should be empirically treated with NAC prior to any laboratory evaluation.
• If the acute ingestion occurred within the past 24 hours, the acetaminophen level should be plotted on the nomogram. If the patient's level is above the toxic level, NAC should be continued
  

• serum pH below 7.3 after adequate fluid resuscitation
  
• INR above 6.5,
• grade III or IV encephalopathy.
• If any of the above criteria are met, serious consideration should be given to transferring the patient to a regional liver transplant center for definitive management
  

• Toxic dose: 150mg/kg
• 4 hr toxic level: 150mcg/ml
• Loading dose: 150mg/kg

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