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Home > Emergency Medical Minute > Episode 966: Acetaminophen Toxicity
Podcast: Emergency Medical Minute
Episode:

Episode 966: Acetaminophen Toxicity
Category: Science & Medicine
Duration: 00:03:39
Publish Date: 2025-07-21 10:00:00
Description:

Contributor: Jorge Chalit-Hernandez, OMS4

Educational Pearls:

  • What is the toxic dose of acetaminophen?
    • 7.5 grams, in an adult. The safe daily limit is 4 grams in an adult with a normally functioning liver.
    • This is equivalent to fifteen 500mg pills.
  • What are the symptoms of acetaminophen toxicity?
    • First 24 hours, symptoms are non-specific e.g. nausea, vomiting, lack of appetite. Can also be asymptomatic.
    • 24-72 hours, hepatotoxicity occurs (causing yellow skin, pruritus, abdominal pain, bleeding, and confusion)
    • Fulminant liver failure at 72-96 hours
    • Liver function tests (LFTs) peak at 72-96 hours.
  • When would you give activated charcoal?
    • Within 4 hours of ingestion.
    • The risk of activated charcoal is that it can be very dangerous if aspirated so use with caution with a poorly mentating patient
  • When would you give N-acetylcysteine (NAC)?
    • The peak absorption of acetaminophen occurs at about 4 hours with acute ingestions
    • Use the Rumack–Matthew nomogram to plot the serum level of acetaminophen versus the time since ingestion to see if you are above the treatment line.
    • If the ingestion time is unknown then just give it.
  • How do you dose NAC?
    • 3 bag system: First, a 150 mg/kg bolus is administered IV over 15-60 minutes (Bag 1), then a 50 mg/kg drip is administered over 4 hours (Bag 2), then a 100 mg/kg drip is administered over the following 16 hours (Bag 3).
      • This is the Prescott Protocol that requires three bag of IV fluids
    • 2 bag system: There is a simplified protocol that only requires 2 bags, 200mg/kg IV over 4 hours (Bag 1) followed by 100mg/kg over 16 hours (Bag 2)
      • Less risk of anaphylactoid reactions with a 2-bag system due to the high rate of IV NAC given in the 3 bag system.
  • What are the end points to stop giving NAC?
    • If the INR is
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