Pediatric emergency medicine trisk 3063 3063
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extended-release preparations. Activated charcoal therapy may be used for
adsorption of gastric APAP, using the same guiding principles for charcoal
administration discussed in the general approach section of this chapter.
In addition to an APAP level, initial diagnostic testing should include baseline
hepatic transaminases, chemistries, and consideration of screening for
coingestants. For patients presenting to care within 24 hours of a single acute
overdose at a known time of ingestion, a nomogram ( Fig. 102.2 ) is available for
using the plasma APAP level in the prediction of likely toxicity. We recommend
using the lower line of the nomogram, plotted 25% below the probable toxicity
line, to err on the safe side in making management decisions. Importantly, the
nomogram is not validated for chronic APAP toxicity and caution should be taken
in interpreting the nomogram in the setting of coingestants that may be associated
with decreased GI motility. In the setting of chronic supratherapeutic ingestion,
multiple ingestions, and unknown time of ingestion, the Rumack-Matthew
nomogram cannot be used to guide management. In these settings, an
undetectable acetaminophen level, normal transaminases, and normal INR
exclude significant toxicity. However, a detectable acetaminophen level and/or
evidence of hepatotoxicity should prompt treatment with NAC.
N -acetylcysteine (NAC), given IV or orally, is most effective at ameliorating
hepatotoxicity when instituted within 8 hours of ingestion. It also lessens the
severity of hepatic damage if used in the setting of clinical presentation beyond 8
hours. The major adverse reaction associated with IV NAC is the occurrence of
anaphylactoid reaction, which typically occurs during the relatively higher-dose
loading infusion. Clinicians administering IV NAC should be skilled at
recognizing and treating anaphylactoid reactions and should be particularly
cautious when using this route in patients with a history of asthma. Although
rarely done, the inhalational form of NAC can be administered enterally and can
be mixed with fruit juice or soda to disguise its foul smell, or it can be
administered by NG tube. Only mild GI side effects result from its use, but
persistent vomiting is an occasional obstacle to completing the course of oral
therapy. This may be obviated by giving the dose slowly or by NG or duodenal
tube infusion. Antiemetic therapy may also be helpful.
The protocol for NAC therapy may be summarized as follows:
1. Consider GI decontamination options as noted in the previous section.
2. If the patient presents less than 4 hours after a single acute ingestion, wait to
draw 4-hour level and base therapeutic decision on nomogram (assumes
rapid turnaround time so level will be available by 6 to 8 hours after
ingestion); if necessary, initiate treatment as described next. For extended-
