Paracetamol Poisoning Notes

Initial Assessment

• 20-year-old male brought to the emergency department for suspected paracetamol overdose.
• Initial Actions:
  • Assess hemodynamic stability.
  • Provide empathy and support to the mother.
  • Use open-ended questions to gather information:
    • "Can you tell me what has happened?"
    • Address concerns with empathy: "I’m so sorry to hear that."

Exploring the Incident

• Inquire about the details of the incident:
  • "Do you know what exactly happened?"
  • "Can you guess a rough time when he took the tablets?"
  • "What medication has he exactly taken? Do you know the types or brand?"
  • "Can you guess how many tablets he has taken?"
  • "Do you know why he has taken these tablets?"

Assessing Hepatotoxicity Risk

• Gather information to evaluate the risk of liver damage:
  • Previous paracetamol use.
  • Alcohol consumption.
  • Use of other drugs or medications.
  • Use of seizure medications.
  • Use of St. John's Wort or other herbal medications.
  • Recent fasting.
  • Previous history of liver disease.

Symptoms of Toxicity

• Assess for the presence of symptoms related to paracetamol toxicity:
  • Nausea.
  • Vomiting.
  • Abdominal pain.
  • Sweating.
  • Dizziness.
  • Confusion.

Psychological Evaluation

• Evaluate the patient's mental state and potential suicide risk:
  • Previous history of suicide attempts or self-harm.
  • Assess if this incident was a suicide attempt.
  • Inquire about the patient's mood before the incident.
  • Ask about stressors at home, work, or school/university.
  • For female patients, inquire about the last menstrual period and possibility of pregnancy.

Investigations

• Relevant investigations to perform:
  • Serum paracetamol level (to determine concentration).
  • Liver function tests (LFTs): AST and ALT (to assess liver damage).
  • Coagulation study: PT/INR (to assess liver function).
  • Full blood examination (FBE).
  • Renal function test: urea, electrolytes, creatinine, eGFR (to assess kidney function).
  • ECG (to assess cardiac function).
  • Blood sugar level (to assess glucose levels).
  • Venous blood gases (to assess acid-base balance).

Management

• Treatment strategies based on time since ingestion:
  • If less than 2-4 hours:
    • Administer activated charcoal to reduce absorption of paracetamol from the gastrointestinal tract.
  • If more than 4 hours:
    • Consider N-acetylcysteine (NAC) administration.
    • Check serum paracetamol concentration and plot it on a nomogram.
      • If the concentration is above the treatment line, administer NAC.
      • If the concentration is below the treatment line, do not administer NAC.