Deaths from low dose paracetamol poisoning

Paracetamol poisoning: Which nomogram should we use?

OBJECTIVES

To determine the type of paracetamol nomograms used in Australasian EDs. To review the literature to determine the evidence base for existing nomograms.

METHODS

A cross sectional descriptive study via postal survey of all Australasian EDs accredited for specialist emergency medicine training by the Australasian College for Emergency Medicine (ACEM). A literature review using Knowledge Finder search engine was employed.

RESULTS

The response rate was 87%. The most commonly used nomogram had a four-hour treatment level of 1300 mumol/L (69%). A total of 22% of respondents used a four-hour treatment level of 1000 mumol/L. Two departments (3%) treated all patients above the 660 mumol/L line. Eleven departments (15%) did not have a treatment line below 1300 mumol/L.

CONCLUSION

Practice varies in Australasian EDs. Patients with paracetamol levels below the 1300 mumol/L have been reported in the literature to develop hepatotoxicity, and deaths have been documented. N-acetylcysteine is extremely safe when used in the recommended dosages.

Treatment strategies for early presenting acetaminophen overdose: a survey of medical directors of poison centers in North America and Europe

BACKGROUND

Acetaminophen is frequently used in self-poisoning in Western countries. Although treatment with N-acetylcysteine (NAC) reduces liver injury, no consensus exists on the preferred management of acetaminophen toxicity.

OBJECTIVES

To describe the approach taken by toxicologists in North America and Europe toward the management of acetaminophen toxicity.

METHODS

Medical directors of poison centers in the US, Canada, and Europe were surveyed by means of a questionnaire presenting two clinical scenarios of acetaminophen overdose: a healthy adolescent with no risk factors who had an acute ingestion of acetaminophen, and an adult with both acute ingestion and possible risk factors. For each case, several questions about the management of these patients were asked.

RESULTS

Questionnaires were sent to medical directors of 76 poison centers in North America and 48 in Europe, with response rates of 62% and 44%, respectively. Forty percent of responders suggested using charcoal 4 hours after ingestion of a potential toxic dose of acetaminophen, and 90% recommended treatment with NAC when levels were above 150 microg/mL but below 200 microg/mL 4 hours after ingestion. Duration of treatment with oral NAC ranged from 24 to 96 hours; 38 responders suggested a duration of 72 hours. Of 49 centers recommending oral NAC, 18 (36.7%) said they might consider treatment for less than 72 hours. Eleven of 29 (37.9%) responders suggested treatment with intravenous NAC for more than 20 hours as their usual protocol or a protocol for specific circumstances.

CONCLUSIONS

Our study showed large variability in the management of acetaminophen overdose. Variations in treatment protocols should be addressed in clinical trials to optimize the treatment for this common problem.