![]() Clinical Implications of Basic Neuroscience.Challenges in Clinical Electrocardiography.ALT indicates alanine aminotransferase AST, aspartate aminotransferase CMP, complete metabolic panel ED, emergency department and PI, post ingestion. A pregnancy test result should be documented for all females of childbearing age. Acetylcysteine should be administered while awaiting acetaminophen concentrations if samples are drawn more than 24 hours after ingestion and the patient has signs and symptoms of toxicity. Prothrombin time and international normalized ratio activity should be measured in patients with an elevated transaminase activity or clinical suspicion of liver injury. A nondetectable concentration at 2 to 4 h after ingestion typically excludes significant ingestion, but consultation with a poison center or toxicologist is recommended. An acetaminophen concentration sample drawn before 4 hours after ingestion cannot be used to risk-stratify patients on the acetaminophen nomogram. ![]() The recommended dose is 50 to 100 g for adults and 25 to 50 g for children. Single-dose activated charcoal (SDAC) should be considered in patients with acute ingestion of a potentially liver-toxic amount of acetaminophen unless the patient is unable to control airway or has contraindications to its use. The physical examination should evaluate signs consistent with acetaminophen poisoning (vital signs, body weight, repeated vomiting, right upper quadrant abdominal tenderness, or mental status change). Medical history includes conditions that may affect the severity of poisoning (eg, long-term alcohol use and underlying liver disease). The initial history should include patient age, intent, specific formulation, dose, time ingestion began, duration of ingestion, pattern of ingestion, and concomitant ingested medications. Despite the 20 and 72 hour protocols, many experts will continue IV NAC for longer, especially in hepatic failure -> typically continued until patient receives a liver transplant, OR until encephalopathy resolves and INR becomes Use IV if patients unable to take PO (obviously) or in all cases of fulminant hepatic failure.Main downside to IV NAC is risk of anaphylactoid reaction (in 10-20%) but usually this can be managed, especially in an ICU setting where the patients belong. In general, both IV and PO are probably equally efficacious.Methods: 20 hour IV protocol vs 72 hour PO protocol Key is to start before you see rise in ALT – the earlier the better! N-acetylcysteine – antidote for acetaminophen: acts by restoring glutathione stores in the liver GI decontamination with activated charcoal – the sooner the betterĢ. Note that acute alcohol ingestion with acetaminophen may actually be protective, due to the fact that EtOH competes with acetaminophen for CYP2E1 metabolism.ġ.Chronic alcohol – due to depletion of glutathione and induction of CYP2E1 enzyme.Normally, NAPQI is scavenged by glutathione in the liver (an antioxidant), but when this is depleted, hepatotoxicity ensues. Remaining 8% is metabolized via CYP2E1 into NAPQI, which is a reactive molecule which causes hepatotoxicity. Normal metabolism of acetaminophen – 90% via liver glucoronidation and sulfation -> excreted harmlessly in the urine.Most cases of poisoning occur with >10 g/day. Max safe dose of acetaminophen per day is ~4 g in adults, but may be lower in predisposed patients such as chronic alcoholics and malnourished patients.
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