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Acetaminophen Overdose 3-18

Terms in this set (19)

Be able to develop a differential diagnosis in a case of acetaminophen toxicity
Gastroenteritis
Peptic ulcer disease
Hepatitis
- alcohol, drug, toxin, viral, ischemic
Hepatorenal syndrome
Inborn errors of metabolism
Reye syndrome
Acute tubular necrosis
Cytomegalovirus infection
Pancreatitis
Mushroom toxicity - Amatoxin
Wilson's disease
Know the management of patients presenting with acetaminophen overdose
1. Known time of ingestion
Know the management of patients presenting with acetaminophen overdose
1. Unknown time of ingestion
start with NAC and manage based on liver function studies
Know the management of patients presenting with acetaminophen overdose
1. Multiple supratherapeutic doses
Understand the pathophysiology of acetaminophen metabolism and how its metabolites harm the body
Know how to utilize the Rumack-Matthew Nomogram and know its limitations
can't adequately measure acetaminophen until 4hrs post-ingestion
Understand the mechanism of N-acetylcysteine and when it should be utilized
replaces glutathione stores

look at nomogram, if pt is above the line, give it if not, wait then recheck
also doesn't work well after 24hrs post-exposure
Understand how co-ingestants may affect acetaminophen toxicity
alcohol can induce P450, acutely inhibiting the microsomal oxidation of APAP. This protects against liver damage. chronic use however,enhances toxicity, thought to be d/t impaired glutathione synthesis
Understand the use of OP&P in the case of acetaminophen toxicity
can use rib raising to support breathing
lymphatic pump
what is considered a minimum toxic dose of acetaminophen in adults after a single acute ingestion?
>7.5gm
define acute overdose
Ingestion of toxic amount within a period of 8 hours or less
define supratherapeutic (chronic) overdose
Ingestion of toxic amount over a period > 8 hours
how do you correct for calcium when there is low albumin?
Corrected calcium = serum calcium + 0.8 (4 - serum albumin)
Recognize the clinical signs and symptoms of acetaminophen toxicity in:
1. stage I
1. <24hrs post-ingestion
can be asymptomatic or have:
N/V
diaphoresis
malaise, anorexia
pallor
normal ALT/AST until 12hrs
Recognize the clinical signs and symptoms of acetaminophen toxicity in:
1. stage II
1. 24-72hrs post-ingestion
initial symptoms go away and the pt feels better, then:
RUQ pain
increased ALT/AST, PT
oliguria, anuria (increased BUN, Cr)
hepatomegaly
Recognize the clinical signs and symptoms of acetaminophen toxicity in:
1. stage III
1. 72-96hrs
jaundice
confusion (d/t hepatic encephalopathy [kernicterus])
fulminant hepatic failure
very increased ALT/AST, ammonia, indirect bilirubin
decreased glucose, lactic acidosis, pancreatitis, AKI
Recognize the clinical signs and symptoms of acetaminophen toxicity in:
1. stage IV
1. 4 days-2 weeks
recovery
no long term liver issues if no disease before poisoning
complete resolution of liver failure, however kidneys may still be damaged
describe the treatment of acetaminophen poisoning
ABC's
History
Exposure Risk Assessment:
- How much? What preparation? When? Pattern of abuse? Intent? Other drug use? Comorbidities that may affect toxicity? Psych history?
Supportive therapy
Labs
- CBC, lytes, BUN, Creat, LFT's, PT/INR, - PTT, others as needed
- Acetaminophen level, salicylate level, alcohol level, urine drug screen
- ECG, CXR
Contact poison control center
Activated charcoal (up to 4 hr)
N-acetylcysteine (NAC)
- antidote
describe the steps in determining if there is an acid/base disorder
Patient history and physical exam

Arterial blood gas
1. Assess pH
2. Assess PaCO2 and [HCO3-]
- pH and PaCO2 move in opposite directions - respiratory
- pH and [HCO3-] move in same direction - metabolic

Once initial change is identified, determine if the other parameter is abnormal
- if change is in the same direction, compensatory response
- if change is in opposite direction, suspect mixed disorder

If respiratory disorder, is it acute or chronic, and is compensation adequate

If metabolic acidosis, look at anion gap, and determine if compensation is adequate
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