Pediatric emergency medicine trisk 0883 0883
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Acetaminophen Toxicity
Acetaminophen toxicity is one of the most common unintentional and intentional
overdoses seen in children and teenagers. The acetaminophen metabolite N acetyl-p -benzoquinoneimine (NAPQI) is responsible for hepatocyte injury by
depleting glutathione, an antioxidant. Liver damage is more likely to occur with
an ingested dose of 150 mg/kg or higher, or over 10 g total. In the first 8 hours
after ingestion the patient can present with vague gastrointestinal symptoms such
as nausea and vomiting, but generally will appear well for the first 24 hours.
Liver enzymes will typically rise after 24 hours, and peak liver damage occurs
between 24 and 48 hours after ingestion, manifesting with coagulopathy,
encephalopathy, or hepatic failure and can progress to death. An acetaminophen
level should be drawn at a minimum of 4 hours after ingestion, and the Rumack–
Matthew nomogram can be used until 24 hours postingestion to determine
toxicity.
Charcoal therapy is recommended only if the patient is seen within 1 hour of
ingestion, is alert with stable vital signs, and is suspected to have ingested a toxic
level of acetaminophen. NAC is given for a toxic level of acetaminophen in the
blood based on the nomogram. NAC is a precursor to glutathione and helps the
body to metabolize and excrete acetaminophen and NAPQI built up in the liver.
Liver enzymes and coagulation studies should be followed serially after ingestion
to monitor for progressive damage and need for further intervention.
Suggested Readings and Key References
Bartlett M. Neonatal jaundice and disorders of bilirubin metabolism. In: Suchy
FJ, Sokol RJ, Balistreri WF, eds. Liver Disease in Children . 4th ed. New York:
Cambridge University Press; 2014.
Brumbaugh D, Mack C. Conjugated hyperbilirubinemia in children. Pediatr Rev
2012;33(7):291–302.
Fawaz R, Baumann U, Ekong U, et al. Guideline for the evaluation of cholestatic
jaundice in infants: Joint Recommendations of the North American Society for
Pediatric Gastroenterology, Hepatology, and Nutrition and the European
Society for Pediatric Gastroenterology, Hepatology, And Nutrition. J Pediatr
Gastroenterol Nutr 2017;64:154–168.
Harb R, Thomas DW. Conjugated hyperbilirubinemia: screening and treatment in
older infants and children. Pediatr Rev 2007;28(3):83–91.
