Paracetamol overdose

Vignette: 24 years old lady admitted after calling her friend for help stating she does not feel well. According to the friend, she was found to be lying on the floor and had vomited. There were empty packets of paracetamol on the floor.

Past medical history: Previous self harm, depression + anxiety

Medications: Nil regular

Observations: HR 105, BP 95/60, Sats 96% on air, RR 18, Temp 37.3

Please discuss you approach in this patient.

Model answer:

Candidate should identify this patient is clinically very unwell + haemodynamically unstable. Should be managed in resus if in ED.

Patient should be assessed in A-E manner, ensuring their airway is safe + GCS stable. An attempt to get history from friend (if present or over the phone) should be made – should explore the potential of overdose – time onset, any empty packets – how many? Explore any history of previous OD? any recent traumatic events?/triggers

Examine patient clinically – this reveals patient to be clammy, rousable but drowsy, complaining of nausea

Investigations: repeat obs/bedside monitoring, bloods including VBG, FBC, U&Es, CRP, glucose, Clotting, paracetamol level, ?salicylate level, ECG

Differentials include: Paracetamol overdose vs polypharmacy overdose

Treatment: A-E manner.

Specific treatment – If presenting within 8 hrs of OD, calculate the total paracetamol ingested but don’t delay treatment if unable to act on results before 8 hrs from ingestion. Candidate may mention toxbase, looking up

SNAP/trust protocol. Should mention IV N-acetylcysteine (NAC) when considering

treatment as well as IV fluids + anti-emetics.

Further History:

Approx 50 pills of 500mg tablets, patient weighs 50 kg. Above threshold for treatment. INR 2.8, ALT 70, mild AKI

GCS 14

How would you manage this patient further?

Candidate should identify that the patient has acute liver injury in context of paracetamol overdose, this would need close monitoring + NAC needs to continue and a referral to liver team is appropriate. High scoring candidate would also mention that they would review the criteria for referral to a liver transplant centre as this may be necessary here.

For Reference:
Suggested criteria for referral to a liver transplant centre