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TOX TABLES

Paracetamol

IMPORTANT SHIT

Toxic dose 150 mg/kg (adult) or 200 mg/kg (Kid)
Toxic normogram level - 150 @4h

If HAGMA or Lactaemia its a bad overdose

Investigations:
Paracetamol level
INR
FBC ? Platelets
BSL
Liver function is ALTerered (ALT the important bit) - peaks at 48h

NAC reaction management (anaphaylactoid)
  • Stop NAC
  • Neb salbutamol
  • Pred 1mg/kg
  • Antihistamine
  • Restart at lower rate
Referral for liver transplant (Asked twice in past exams)
HE CRASH
  • Hypoglycaemia
  • Encephalopathy
  • Coagulopathy (INR >3 @48 h)
  • Renal failure
  • Acidosis (pH <7.3)
  • Severe thrombocytopaenia
  • Hypotension (SBP <80)

SPECIFIC ANTIDOTE

PARACETAMOL (ie: Normal release)
Normal paracetamol - Charcoal: <30g and <2h, or >30g and <4h. no role after 4h. No role in Liquid Paracetamol as absorbed too quick
  • <8 hrs = ALT and Paracetamol at 4-8 hours + plot, High dose if >2x normogram
  • 8-24 hours = Start Standard NAC, Stop if bloods OK, High dose if >2x normogram
  • >24h = Start Standard NAC, can stop when paracetamol <10 and ALT <50
NAC Dose (2 bag, 20 hours)
  • BAG 1: acetylcysteine 200 mg/kg (up to 22 g) in crystalloid solution 500 mL intravenously, over 4 hours (7mL/kg up to 500 mg in kids)
  • BAG 2: acetylcysteine 100 mg/kg (up to 11 g) in crystalloid solution 1000 mL intravenously, over 16 hours (14 mL/kg up to 1000 mL in kids) (In HIGH DOSE - this is 200 mg/kg in second bag not 100 mg/kg)
Check LFT’s + paracetamol 2 hours before completion - if ALT >50 (or worse than regulary baseline derangement), or if concentration >10 → Extended dose NAC
EXTENDED DOSE NAC = acetylcysteine 100 mg/kg (up to 11 g) in crystalloid solution 1000 mL intravenously, over 16 hours (Ie: Repeat the second bag)

Extended Release Paracetamol:
Extended release - Activated charcoal 1g/kg if <4h since ingestion
Start NAC:
  • <10g (200 mg/kg for ppl<50 kg) = can wait for bloods
  • 10-30g = Start normal dose NAC
  • > 30g (500g/kg) start High dose NAC
Bloods at presentation/4h post ingestion (repeat 4h later). If any above result above normogram >> normal dose NAC. If double normogram at any point - High dose NAC
All from eTG
Self-rate:
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