The antidote to acetaminophen overdose is N- acetylcysteine (NAC). It is most effective when given within eight hours of ingesting acetaminophen. Indeed, NAC can prevent liver failure if given early enough. For this reason, it is absolutely necessary that acetaminophen poisoning be recognized, diagnosed, and treated as early as possible.
What is the treatment for acetaminophen overdose?
Treatment depends on how much time has passed since the overdose and if the overdose happened all at one time: Activated charcoal medicine may be given to soak up the acetaminophen that is still in your stomach. Activated charcoal will make you vomit.
What is another name for acetaminophen toxicity?
Other names: Acetaminophen Toxicity. About Acetaminophen Overdose: Acetaminophen (Tylenol) is a pain medicine. Acetaminophen overdose occurs when someone accidentally or intentionally takes more than the normal or recommended amount of this medication.
When to seek medical care for acetaminophen (Tylenol) poisoning?
When to Seek Medical Care for Acetaminophen (Tylenol) Poisoning. A person or caregiver must call a doctor, poison control center, or emergency medical services for any suspected acetaminophen overdose. Overall it is important that anyone suspected to have taken an overdose of acetaminophen get treatment early, before symptoms occur.
When should EMS be called for acetaminophen toxicity?
In some situations, EMS may not be called until toxic symptoms develop. In the first 12 to 24 hours after acetaminophen ingestion, symptoms are generally limited to nausea, vomiting, malaise and decreased appetite. Frank liver failure is usually not seen until two to three days after an acute ingestion.
Which medication is given for acetaminophen overdose?
Oral N-Acetylcysteine The oral formulation of NAC (Mucomyst) is the drug of choice for the treatment of acetaminophen overdose.
What are the nursing interventions of acetaminophen?
Possible Nursing DiagnosesAcetaminophen Nursing InterventionsRationaleMonitor for any symptoms of diarrhea or hepatic/ liver damage, and treat these as they appear.Acetaminophen may cause diarrhea as well as hepatic damage.3 more rows
How do you stop acetaminophen toxicity?
Keep all medication out of the reach of children and securely locked up. Know the correct dose of acetaminophen and the amount of acetaminophen in the preparation you are using. If taken in recommended doses, there is no risk of poisoning from acetaminophen.
Which drug is used for patient with acetaminophen overdose to help the liver detoxify?
The antidote to acetaminophen overdose, N-acetylcysteine (NAC), is most effective when given within 8 hours of ingesting acetaminophen and can prevent liver failure, if given early enough, by replenishing the stores of glutathione in the liver to detoxify NAPQI.
What drugs should not be taken with acetaminophen?
Drug interactions of Tylenol include carbamazepine, isoniazid, rifampin, alcohol, cholestyramine, and warfarin. Tylenol is often used during pregnancy for short-term treatment of fever and minor pain during pregnancy.
What class of medication is acetaminophen?
Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers).
How does N-acetylcysteine work in acetaminophen overdose?
Abstract. N-Acetylcysteine is the drug of choice for the treatment of an acetaminophen overdose. It is thought to provide cysteine for glutathione synthesis and possibly to form an adduct directly with the toxic metabolite of acetaminophen, N-acetyl-p-benzoquinoneimine.
Is acetylcysteine a mucomyst?
Acetylcysteine is available under the following different brand names: N-acetylcysteine, and Mucomyst.
What antidote should be used in the first 10 hours in paracetamol poisoning?
Paracetamol poisoning was first reported in 1966. The development of antidotes followed within 10 years, and by 1980 acetylcysteine (NAC) was acknowledged as the optimal therapy available.
What is acetylcysteine as antidote for?
N-acetylcysteine (NAC), a GSH precursor, is the only currently approved antidote for an acetaminophen overdose. Unfortunately, fairly high doses and longer treatment times are required due to its poor bioavailability. In addition, oral and I.V. administration of NAC in a hospital setting are laborious and costly.
When do you give acetylcysteine?
The American College of Emergency Physicians recommends acetylcysteine therapy for any patient with acute acetaminophen ingestion and a timed serum concentration above the line that begins at 150 μg per milliliter at 4 hours, as well as for any patient with liver injury or liver failure.
What is the use of acetylcysteine?
Acetylcysteine inhalation is used along with other treatments to relieve chest congestion due to thick or abnormal mucous secretions in people with lung conditions including asthma, emphysema, bronchitis and cystic fibrosis (an inborn disease that causes problems with breathing, digestion, and reproduction).
What is acetaminophen poisoning?
Acetaminophen poisoning is an overdose of the over-the-counter (OTC) pain medication, acetaminophen (eg, Tylenol, Biogesic), which is usually safe when used as recommended.
What tests are done to determine the level of acetaminophen in your blood?
Diagnosis. Blood Tests —Blood tests are done to determine the level of acetaminophen in your blood and to determine liver function (eg, liver enzyme tests, coagulation tests). Rumack-Matthew Nomogram—This is an assessment to determine the effect on the liver.
Can you give acetaminophen by mouth?
In most cases of toxic acetaminophen overdose, N-acetylcysteine, an amino acid, will be given by mouth or IV (through the vein) as an antidote. Matt Vera, BSN, R.N. Matt Vera is a registered nurse with a bachelor of science in nursing since 2009 and is currently working as a full-time writer and editor for Nurseslabs.
Can acetaminophen cause liver failure?
Combining medications that contain acetaminophen (Acetaminophen is found in more combination products than any other drug; examples include acetaminophen and codeine, as well as acetaminophen and aspirin .) Toxic levels of acetaminophen may also occur in patients with liver failure who are taking recommended doses.
What is acetaminophen overdose?
Acetaminophen overdose means taking more than it is safe to take. It may also be called acetaminophen poisoning. Acetaminophen is called paracetamol in countries outside the United States. When used correctly, acetaminophen is a safe drug that decreases pain and fever.
How long does it take for acetaminophen to cause nausea?
If the overdose is treated right away, you might have fewer or easier symptoms in the later stages. First 24 hours : Nausea, vomiting, stomach pain, and loss of appetite. Paleness.
How long does acetaminophen last?
Do not take acetaminophen for more than 10 days to treat pain, unless your healthcare provider tells you to. Do not take acetaminophen for more than 3 days to treat a fever, unless your healthcare provider tells you to. Your pain or fever may need to be treated another way if it lasts longer than a few days.
What tests are used to check acetaminophen levels?
You may also need any of the following: Blood tests are used to check the amount of acetaminophen in your blood. Liver function tests may show if your liver is working properly. Prothrombin time (PT) and INR rates measure how long it takes for your blood to clot.
Can you overdose on acetaminophen?
You might accidentally take too much if your pain or fever did not go away after the recommended dose. You may also get too much if you take acetaminophen for too many days in a row.
Can you take acetaminophen and acetaminophen together?
Do not take these medicines together with acetaminophen. The combined amount of acetaminophen may be too much. Take the correct dose. Make sure you take the right amount and wait the right number of hours between doses. Never take more than the label says to take. Do not take acetaminophen for more days than directed.
Can you take acetaminophen with extended release?
When you take extended-release pills, the medicine stays in your body longer. You are supposed to take these medicines less often than you would take regular acetaminophen. If you take this medicine too often, you will have too much in your body at one time .
How to avoid acetaminophen overdose?
People can take these steps to avoid acetaminophen overdose. Always securely close acetaminophen containers and use child-proof bottles. Keep all medication out of the reach of children and securely locked up. Know the correct dose of acetaminophen and the amount of acetaminophen in the preparation being are used.
What to do if you overdose on acetaminophen?
If the person suspected to have taken an overdose of acetaminophen is unconscious, semiconscious, or not breathing, call 911 immediately. Go to the hospital's emergency department if the poison control center instructs you to do so. Seek emergency care if you are unsure of the types and amounts of medication taken.
How to give acetaminophen to a person?
This can be accomplished by inducing vomiting or by placing a large tube through the person's mouth and into the stomach, putting fluid in and then pumping it out (gastric lavage). N-acetylcysteine (NAC): NAC is the antidote for toxic acetaminophen overdose. It is generally given by mouth.
What are the symptoms of acetaminophen poisoning?
Physical: The doctor will look for signs and symptoms of acetaminophen poisoning. These may include jaundice ( yellow skin ), abdominal pain, vomiting, and other signs and symptoms. Laboratory tests: A blood level of acetaminophen will aid in determining if a toxic dose was taken.
What is the active ingredient in Tylenol?
Acetaminophen is the active ingredient in Tylenol. It is also found in many other over-the-counter medications people can buy at the drug store and in many prescription drugs. Common drugs include: Actifed. Alka-Seltzer Plus.
How long does it take to get symptom free after taking Tylenol?
Soon after taking an overdose of acetaminophen, the person may have no symptoms from taking a toxic amount. They may remain symptom free for up to 24 hours after taking a toxic overdose of acetaminophen. After this initial period, the following symptoms are common in acetaminophen (Tylenol) poisoning: Nausea. Vomiting.
What happens if you take a toxic overdose?
If a toxic dose is taken and emergency treatment is delayed, liver failure may follow. Liver failure may mean that a liver transplant is needed. Alternatively, if treatment of a toxic overdose is begun early, the person may recover with no long-term health problems.
What is the most common drug used in analgesics?
The drug most commonly involved in analgesic ingestions, as a single agent or in combination, is acetaminophen. Hepatotoxicity, the major manifestation of acetaminophen ingestion, is believed to result from the accumulation of a toxic metabolite, N-acetylimidoquinone.
Is acetaminophen a single agent?
The assessment and treatment of acute acetaminophen toxicity are reviewed, and several unresolved issues are discussed. The drug most commonly involved in analgesic ingestions, as a single agent or in combination, is acetaminophen. Hepatotoxicity, the major manifestation of acetaminophen ingestion, is believed to result from the accumulation of a toxic metabolite, N-acetylimidoquinone. The clinical features of acetaminophen toxicity are divided into four stages ranging from minor symptoms, such as gastrointestinal irritation, to coma and death. The most reliable method for assessing the severity of acetaminophen ingestion is comparison of serum acetaminophen concentrations with the Rumack-Matthew nomogram. Delaying the start of antidotal therapy for more than 10 hours after the ingestion increases the risk of toxicity; no benefit is observed when antidotal therapy is initiated more than 24 hours after ingestion. Acetaminophen is often marked in combination with other drugs; a detailed patient history and a urine toxicology screen help determine whether multiple toxic ingestions have occurred. The roles of ipecac, gastric lavage, and activated charcoal in therapy are controversial. The mainstay of treatment for acetaminophen intoxication is a 17-dose course of acetylcysteine.
How to manage acetaminophen overdose?
Acetaminophen overdose can be effectively managed by focusing on a few basic principles. As in all cases of poisoning, healthcare providers should obtain a careful history and should have a high index of suspicion. When acetaminophen overdose is a possibility, an acetaminophen level should be obtained and antidotal therapy should be initiated as indicated in these guidelines. When acetylcysteine is administered soon after an overdose occurs, morbidity is significantly reduced and mortality virtually eliminated. The prognosis for patients with acetaminophen overdose is excellent, provided treatment is given expeditiously and appropriately.
How long does it take to overdose on acetaminophen?
Acute acetaminophen overdose is defined as an ingestion of a toxic amount of acetaminophen occurring within a period of 8 hours or less. In adults and adolescents, hepatotoxicity may occur following ingestion of greater than 7.5 to 10 grams (g) (eg, 24 regular-strength or 15 extra-strength caplets or tablets) over a period of 8 hours or less. Fatalities are infrequent especially when treated with acetylcysteine (0.3% of treated cases).
How long does acetaminophen last?
The first phase begins shortly after ingestion of a potentially toxic overdose and lasts for 12 to 24 hours. The patient may manifest signs of gastrointestinal irritability, nausea, vomiting, anorexia, diaphoresis, and pallor. The larger the overdose, the more likely it is that these symptoms are pres-ent. Coma or other evidence of central nervous system depression is usually not present unless the patient has taken a massive overdose or has also ingested central nervous system depressants, as may be the case in suicide attempts. Coma accompanied by severe metabolic acidosis has rarely been reported following acetaminophen overdose, but the loss of consciousness was thought to be secondary to the metabolic acidosis rather than the acetaminophen itself. In small children, spontaneous vomiting following a substantial overdose occurs frequently and may play a role in the reduced risk of toxicity in children. However, these symptoms are not unique to acetaminophen, and unless the possibility of acetaminophen overdose is considered during this early phase, it may be overlooked. Many patients with early symptoms never progress beyond the first phase and recover without additional problems.
How long after overdose can you take acetylcysteine?
If a patient presents within 4 hours of an acute overdose, treatment with acetylcysteine should be withheld until acetaminophen assay results are available, provided that initiation of treatment is not delayed beyond 8 hours following the ingestion.
Does acetaminophen cause delayed elevation?
The ingestion of acetaminophen-diphenhydramine or acetamino-phen-opioid products have been associated with delayed elevations of the acetaminophen level. Patients with rising acetamino phen levels require closer management and may require prolongation of acetylcys-teine treatment*. For patients with initial acetamino phen levels that are unexpectedly low, or with exposures involving the above combination products or additional drugs that could affect acetamino phen absorp-tion, a second acetamino phen level at least 4 to 6 hours after the first measurement is recommended.
Is acetylcysteine approved by the FDA?
Both intravenous and oral formulations of acetylcysteine are available and approved by the US FDA. The oral formulation has been used for many years in the United States. Intravenous administration has become the most common route of acetylcysteine treatment (www.acetadote.net); however, either the oral or intravenous drugs are acceptable for most patients.
Is acetaminophen extended release?
There are multiple products available that contain an extended release formulation of acetaminophen. In cases of overdose, the concern is that absorption of extended release acetaminophen is slower than that of immediate release acetaminophen. As a result, the acetaminophen level could plot below the treatment line of the nomogram at 4 hours, but rise above the treatment line with continued absorption.
Definition
- Acetaminophen poisoning is an overdose of the over-the-counter (OTC) pain medication, acetaminophen(eg, Tylenol, Biogesic), which is usually safe when used as recommended.
- The maximum daily dose of acetaminophen is four (4) grams, but patients with chronic diseases (especially liver disease) may need to limit themselves to three (3) grams a day.
- Acetaminophen poisoning may occur as a result of one large dose or chronic overdoses.
Causes
- An overdose of acetaminophen can result from: 1. Intentional overdose (eg, suicideattempt) 2. Accidental overdose (eg, unsupervised children, altered judgment regarding appropriate acetaminophen intake) 3. Combining medications that contain acetaminophen (Acetaminophen is found in more combination products than any other drug; examples include acetaminophen and …
Risk Factors
- The following factors increase your chance of developing acetaminophen poisoning: 1. Age: 15-24 years or older than 40 years (People over 40 are more likely to have severe effects.) 2. Gender: female 3. Suicidal behavior
Symptoms
- Symptoms include: 1. Nausea 2. Vomiting 3. Excessive sweating 4. Pale skin 5. Symptoms of liver failure: 5.1. Anorexia 5.2. Nausea 5.3. Vomiting 5.4. Malaise 5.5. Abdominal pain (especially in the upper right portion of the abdomen) 5.6. Pale skin 5.7. Excessive sweating 5.8. Jaundice 5.9. Confusion 5.10. Stupor
Diagnosis
- BloodTests—Blood tests are done to determine the level of acetaminophen in your blood and to determine liver function (eg, liver enzyme tests, coagulation tests).
- Rumack-Matthew Nomogram—This is an assessmentto determine the effect on the liver. The test measures blood levels of acetaminophen relative to the time since ingestion of the medication.
Treatment
- Monitoring 1. For children who have relatively low levels of acetaminophen in their blood, monitoring at home may be recommended. Activated Charcoal 1. Activated charcoal can help prevent acetaminophen from absorbing in the gastrointestinal tract. It is taken by mouth. N-acetylcysteine 1. In most cases of toxic acetaminophen overdose, N-acetylcysteine, an amino ac…
Definition
- Acetaminophen overdose means taking more than it is safe to take. It may also be called acetaminophen poisoning. Acetaminophen is called paracetamol in countries outside the United States. When used correctly, acetaminophen is a safe drug that decreases pain and fever. Many medicines contain acetaminophen, including some that you can buy without a prescription.
Risks
- The most acetaminophen that is safe for most people to take is 4,000 milligrams (4 grams) in a 24-hour period. An overdose means you have taken more than is safe in a 24-hour period. The following are ways an unplanned overdose may happen:
Symptoms
- You might not have any signs or symptoms at first. Early signs and symptoms may make you feel like you have the flu. Common signs and symptoms happen during each stage of an acetaminophen overdose. If the overdose is treated right away, you might have fewer or easier symptoms in the later stages.
Diagnosis
- Tell your healthcare provider when you took the acetaminophen and how much you took. He may ask how long you have been taking acetaminophen. He may ask about other medicines you take and when you take them. He may ask if you have any medical problems, such as liver disease. He may ask if you drink alcohol and how much you drink. He will take your blood pressure and temp…
Treatment
- Acetaminophen overdose is a serious problem. Treatment should be started as soon as possible. Treatment depends on how much time has passed since the overdose and if the overdose happened all at one time. You may be given activated charcoal medicine to soak up the acetaminophen that is still in your stomach. Activated charcoal will make you vomit. ...
Resources
- Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.
Mechanism and Pharmacokinetics
Signs and Symptoms
- Stage I – 0-24 hours:anorexia, nausea, vomiting, diaphoresis, lethargy, malaise, pallor; may also be asymptomatic, especially early. Massive ingestions (e.g., serum levels >500 mg/L) can cause acut...
- Stage II – 24-72 hours:stage I symptoms may improve, but laboratory values will worsen, with elevated hepatic aminotransferases (usually AST first, then ALT) by 36 hours. Will develop R…
- Stage I – 0-24 hours:anorexia, nausea, vomiting, diaphoresis, lethargy, malaise, pallor; may also be asymptomatic, especially early. Massive ingestions (e.g., serum levels >500 mg/L) can cause acut...
- Stage II – 24-72 hours:stage I symptoms may improve, but laboratory values will worsen, with elevated hepatic aminotransferases (usually AST first, then ALT) by 36 hours. Will develop RUQ pain, ten...
- Stage III – 72-96 hours:same symptoms as in stage I return, along with jaundice, hepatic encephalopathy, drastic LFT rise, elevated ammonia, and coagulopathy. Patients with severe hepatotoxicity wi...
- Stage IV – 96 hours-2 weeks:recovery phase. Usually is complete by 7 days post-ingestion, b…
Evaluation
- If possible, determine dose, single ingestion or recurrent, time since ingestion, intentional vs accidental, baseline liver disease or risk factors.
- Obtain serum acetaminophen concentration immediately and at 4 hours from ingestion (if known) or presentation (if not known).
- Obtain BMP, LFTs, coagulation factors, urinalysis, urine toxicology; consider other causes of …
- If possible, determine dose, single ingestion or recurrent, time since ingestion, intentional vs accidental, baseline liver disease or risk factors.
- Obtain serum acetaminophen concentration immediately and at 4 hours from ingestion (if known) or presentation (if not known).
- Obtain BMP, LFTs, coagulation factors, urinalysis, urine toxicology; consider other causes of acute liver failure.
- Evaluate 4-hour serum concentration on Rumack-Matthew nomogram: if value is above the treatment line, NAC should be administered.
Initial Management
- Activated charcoal: single dose activated charcoal at 1g/kg (or 50g) PO or via NG tube to all patients within 4 hours of ingestion. May be helpful >4h if co-ingestion is present.
- N-acetylcysteine (NAC): low threshold to treat, given low toxicity and cost. Best if given within 8 hours of ingestion and before ALT rise. Can give with charcoal.
- Antiemetics: ondansetron, metoclopramide; especially important to give with PO NAC.
- Activated charcoal: single dose activated charcoal at 1g/kg (or 50g) PO or via NG tube to all patients within 4 hours of ingestion. May be helpful >4h if co-ingestion is present.
- N-acetylcysteine (NAC): low threshold to treat, given low toxicity and cost. Best if given within 8 hours of ingestion and before ALT rise. Can give with charcoal.
- Antiemetics: ondansetron, metoclopramide; especially important to give with PO NAC.
- Call Poison Control (800-222-1222) for further guidance.
Monitoring
- Check LFTs and INR q12h; if ALT>1000, also check BMP q12h to monitor for renal failure. Severe illness may require more frequent lab monitoring.
- Check serial APAP levels if concerned for delayed absorption; can continue NAC until APAP levels undetectable and LFTs and coagulopathy improving.
- Normal transaminases 24 hours after ingestion indicate very low risk of hepatotoxicity (assu…
- Check LFTs and INR q12h; if ALT>1000, also check BMP q12h to monitor for renal failure. Severe illness may require more frequent lab monitoring.
- Check serial APAP levels if concerned for delayed absorption; can continue NAC until APAP levels undetectable and LFTs and coagulopathy improving.
- Normal transaminases 24 hours after ingestion indicate very low risk of hepatotoxicity (assuming APAP now undetectable).
- Evaluate potential need for liver transplant: consult GI earlyfor severe transaminitis with rising INR and bilirubin. Calculate Kings College criteria for liver transplant, which include pH <7.3, c...
Key Points
- Amount of ingestion and time to treatment are most prognostic of subsequent hepatotoxicity.
- Low threshold to initiate treatment with N-acetylcysteine, with greatest benefit of intervention within 8 hours of ingestion.