Pediatric emergency medicine trisk 3064 3064
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release preparations, McNeil Consumer Products Co. (Fort Washington,
Pennsylvania), a manufacturer of acetaminophen, suggests a second APAP
level drawn 4 hours after the first; antidotal therapy is to be instituted if
either level suggests possible toxicity. If the patient has coingested
substances that may slow gastric motility (opioids, anticholinergics) and the
first level is below the treatment line, draw a second level 4 hours after the
first and initiate treatment if the second level is above the treatment line.
3. If the patient presents more than 6 to 8 hours after ingestion, initiate NAC
therapy, obtain level, and base subsequent course of therapy on nomogram.
4. Treatment for patients who present more than 24 hours after ingestion is
controversial, as is treatment for patients with subacute, repetitive
overdosing over several days or patients with an unknown time of ingestion.
We consider children who receive more than 150 mg/kg/day for 1 to 2 days
to be at risk; but a combination of an undetectable APAP level, normal
aminotransferases, and normal INR identifies a patient at low risk of hepatic
injury from APAP. However, in these settings, either a detectable APAP level
or evidence of hepatotoxicity should prompt treatment with a course of
NAC.
5. If treatment with NAC is indicated, admit the patient to hospital and
continue NAC until APAP is undetectable in the blood, until transaminases
are improving, and until hepatic function (typically assessed via INR) is
normalizing. Monitor daily transaminases, INR, renal function, and APAP
level to guide decision to continue NAC.
