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acetaminophen overdose

Terms in this set (27)

OTC APAP products
sudafed, excedrin, theraflu, dayquil, coricidin cold and flu
mechanism of toxicity
buildup of toxis metabolite NAPQI
glutathione makes NAPQI nontoxic
metabolism during overdose
-conjugation becomes saturated and shifts metabolism to CYP450
glutathione source becomes depleted before NAPQI is metabolized to nontoxic metabolite
-free NAPQI binds to hepatic cells and leads to hepatotoxicity
stage 1 duration
first 24 hrs
stage 1 clinical symptoms
GI (N/V/anorexia)
malaise
pallor
diaphoresis

massive OD = lethargy/decreased consciousness
stage 1 lab findings
hypokalemia

massive OD = metabolic acidosis
stage 2 duration
days 2-3
stage 2 clinical symptoms
abd pain/hepatic tenderness
stage 2 lab findings
AST/ALT >1000 U/L

massive overdose =
met acidosis,
prolonged PT,
bilirubin elevation,
hypoglycemia
stage 3 duration
days 3-4
stage 3 clinical symptoms
fulminant liver failure --jaundice/encephalopathic

multi organ failure
-anuric
-coagulopathies
-pancreatitis

coma
stage 3 lab findings
AST/ALT >10,000 U/L

increased lactate
met acidosis
hypoglycemia
increased SCr/BUN
decreased UOP
prolonged PT
bilirubin elevation
stage 4 duration
days >5
stage 4 clinical symptoms
scenarios:
1- start to improve over 2 weeks
2-continue to deteriorate
3-die
toxic doses acute
toxic = 6-7g, 200mg/kg children
hepatotoxic = 10-15 g
fatal = 20-25 g
toxic doses chronic
> or = 100mg/kg for 3 or more days in a row

> or = 150mg/kg (or 6 g) for 2 or more days
glutathione depleted at
15 g
max dose of APAP
4 g
rumack matthew nomogram
4 hrs post-ingestion concentrations

plot on nomogram
limitations to rumack matthew nomogram
not applicable if time of ingestion unknown
not useful in chronic ingestion
not reliable for patients on extended release
doesnt account for "at-risk" populations
-alcoholics, malnourished, CYP450 inducers, low glutathione stores
treatment options--4
GI decontamination
-activated charcoal
-gastric lavage/whole bowel irrigation
supportive care
-possible intubation
-management of hepatic/renal failure
-antiemetics
antidote
liver transplant
activated charcoal
within 1-2 hrs
gastric lavage/whole bowel irrigation
not recommended because APAP is absorbed so quickly
antidote
n-acetylcysteine
N-acetylcysteine
-what it does
-benefit window
-indications (5)
-used to replenish glutathione stores
-max benefit within 8-10 hrs
indications--probable/possible hepatotoxicity based on:
-rumack matthew nomogram
-evidence of hepatotixicity
-apap concentration >5mg/dL and unknown time of ingestion
-apap concentration not available
-fulminant hepatic failure
NAC IV indications
pregnant
altered mental status
fulminant hepatic failure
NAC info
max wt 100kg
oral = iv in efficacy
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