TOPLINE:
An expert panel has updated recommendations for emergency department assessment, management, and treatment of acetaminophen poisoning.
METHODOLOGY:
The United States and Canada have no formal guidelines for managing acetaminophen poisoning, which is characterized by hepatocellular damage and potential liver failure, which can be life-threatening.
The past 25 years has seen the introduction of products that contain greater amounts of acetaminophen, extended-release preparations, and new drugs that combine acetaminophen with opioids or other ingredients.
From the medical literature and current poison control guidelines, the panel used a modified Delphi method to create a decision framework and determine appropriate management, including triage and laboratory evaluation, for acetaminophen poisoning, addressing scenarios such as extended-release and high-risk ingestion, co-ingestion of anticholinergics or opioids, pregnancy, weight greater than 100 kg, and criteria for consultation with a toxicologist.
TAKEAWAY:
The panel emphasized the role of the patient’s history; an inaccurate estimate of the time of ingestion, for example, can lead to the erroneous conclusion that acetylcysteine, a medication used to treat overdose, is not needed or can be discontinued prematurely – a potentially fatal mistake.
The initial dose of acetylcysteine should be administered as soon as the need becomes evident, with the panel recommending at least 300 mg/kg orally or intravenously during the first 20 or 24 hours of treatment.
Management of ingestion of extended-release preparations is the same, with the exception of obtaining a second acetaminophen blood concentration in some cases.
When acetaminophen is co-ingested with anticholinergic or opioid agonist medications, management is the same, except if the first acetaminophen concentration measured at 4-24 hours after ingestion is 10 mcg/mL or less, another measurement and acetylcysteine treatment are not needed.
IN PRACTICE:
“A guideline that provides management guidance could optimize patient outcomes, reduce disruption for patients and caregivers, and reduce costs by shortening the length of hospitalization,” write the authors.
SOURCE:
The study was conducted by Richard C. Dart, MD, PhD, Rocky Mountain Poison and Drug Safety, University of Colorado, Denver, and colleagues. It was published online in JAMA Network Open.
LIMITATIONS:
The work lacked high-quality data that address clinical decisions needed for managing acetaminophen poisoning. There were only a few well-controlled comparative studies, which focused on specific issues and not on patient management.
DISCLOSURES:
The work was supported by a grant from Johnson & Johnson Consumer Inc. Dr. Dart has reported receiving grants from Johnson & Johnson outside the submitted work. See paper for disclosures of other authors.
A version of this article appeared on Medscape.com.