Episode #23- Acetaminophen Poisoning Management: US & Canada Consensus Statement with Co-Author Dr. Richard Dart, MD, PhD

The Poison Lab

• Mini episode- High-yield over view of Management of Acetaminophen Poisoning in the US and Canada Consensus Statement

In this Ryan sits down with Dr. Richard Dart MD, PhD. He is the lead author of the recently released "Management of Acetaminophen Poisoning in the US and Canada Consensus Statement" from the American Academy of Clinical Toxicology, American College of Medical Toxicology, Americans Poisons Centers, and the Canadian Association of Poison Centers. Listen to be informed on the most recent treatment recommendations. They dive in to the definitions established by the guideline and notable treatment recommendations, dissecting the ratinonale for each desiscion point and how to apply the guidelines. A mini episode was released along side this episode that is a high yield review of major treatment recommendations and definitions estabilished by the consensus statement.

Links :

• Mini episode- High-yield over view of Management of Acetaminophen Poisoning in the US and Canada Consensus Statement
• Guidelines https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808062

Definitions made by the guideline

• Acute ingestion
  • Any overdose taken with 24 hours period
    • Overdose "dose" not defined
      • >7.5 g in 24 h was criteria for Rumack Matthew nomogram
      • Consensus statement
        • Adult overdose at 10g/d or 200 mg/kg/d in <24 hours= potentially toxic
        • Pediatric <6 year at 150 mg/kg/d in <24 h = potentially toxic
• Repeated Supra Therapeutic Ingestion (RSTI)
  • Overdose "dose"
    • Repeated dosing totaling
      • 6g/d or 150 mg/kg/day x 24-48 h = potential toxic
      • 4g/d or 100 mg/kg/day x >48 h = potential toxic (Recognize this means some people could be toxic at therapeutic dosing, but if they do not have symptoms not likely)
• High risk ingestion
  • Reported dose >30 grams OR
  • [APAP] 2 x Rummack-Matthew nomogram treatment line
• NAC stopping criteria
  • APAP<10
  • INR<2
  • AST/ALT Normal for patient or decreased by 25-50%
  • Patient clinically well

Notable treatment recommendations

• RSTI
  • If patient has history of RSTI (>6 g x 24-48 h, >4 g x >48 hours) AND signs of APAP toxicity (vomiting, RUQ abd pain, AMS)
    • Treat if APAP >20 ug/ml OR AST/ALT elevated
• Acute
  • Non-detectable [APAP] between 2 and 4 hours excludes ingestion
  • Give SDAC w/in 4 hours (something I’ve been a proponent of since ATOM2)
• Treat
• Start treatment with NAC if unable to plot on nomogram by 8 hours
• NAC dose
  • “Higher dose” NAC (undefined) for high risk ingestion
  • Minimum NAC regimen should include 300 mg/kg orally or within 20-24 hours
  • CAP NAC dose at 100 kg (this was known with PO, but IV there was always some question since it delivers less overall)
• Unique scenarios
  • Line crossers
    • APAP with anticholinergic or opioid
      • If 1st concentration below treatment line repeat in 4-6 hours
    • APAP Extended release
      • If 1st concentration below treatment line @ 4-12 hours, repeat in 4-6 hours
  • Dialysis-
    • Dialyze If APAP >900 w/ AMS or acidosis.
    • NAC IV rate during HD 12.5 mg/kg/hr minimum. No dose change for PO (not new but good reminders)
• Consult liver transplant for rapid AST/ALT inc w/ coagulopathy, AMS, or mulistytem organ failure
• The addition of fomepizole to acetylcysteine in the treatment of serious acetaminophen ingestions has been proposed. The panel concluded that the data available did not support a standard recommendation. As for any complicated or serious acetaminophen poisoning, a PC or clinical toxicologist should be consulted.