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 μg/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 School of Medicine, Denver, and colleagues. It was published online August 8 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. Dart has reported receiving grants from Johnson & Johnson outside the submitted work. See paper for disclosures of other authors.

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