Management

If ingestion has occurred <4h previously, gastric elimination techniques should be employed. Paracetamol levels may be taken to confirm ingestion but should not be interpreted for toxicity until after 4h from ingestion. The mainstay of treatment is with W-acetylcysteine to restore hepatic glutathione levels by increasing intracellular cysteine levels.

N-acetylcysteine

Treatment is most effective if started within 10h of ingestion but is currently advised for up to 36h of ingestion. Treatment is required if the paracetamol levels are in the toxic range (see figure) or >15g paracetamol has been ingested. It should be continued until paracetamol is not detected in the blood. W-acetylcysteine is given by continuous IV infusion (150mg/kg over 15min, 50mg/kg in 500ml 5% glucose over 4h then 50mg/kg in 500ml 5% glucose 8-hrly).

Complications

The major complication is hepatic (± renal) failure. A rise in prothrombin time, INR and bilirubin are early warning signs of significant hepatic damage and this should prompt early referral to a specialist centre.

Guidelines for referral to a specialist liver centre

• Oliguria and/or rising creatinine

• Altered conscious level

• Hypoglycaemia

Guidelines for liver transplantation

Plus all of the following:

• Creatinine >300pmol/l

• Grade 3-4 encephalopathy

High lactate levels (>3.5mmol/l at 4 and 12h) and low factor V levels are also associated with a poor outcome if not transplanted.

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