EMCrit 351 - Severe Acetaminophen (Tylenol) Toxicity
Jun 15, 2023
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Exploring the management of severe acetaminophen toxicity, including challenges in diagnosis, lab tests, and NAC dosing protocols. Discussion on femepazol as an ancillary therapy, dialysis recommendations, and treatment strategies. Insights on monitoring liver failure patients and potential NAC interactions with coagulation factors.
Massive acetaminophen ingestion may not fit traditional toxicity profiles, requiring a high index of suspicion for severe cases.
Early initiation of acetylcysteine treatment based on clinical suspicion is crucial in managing severe Tylenol poisonings.
Deep dives
Defining Massive Acetaminophen Ingestion
Massive acetaminophen ingestion lacks a unanimous definition in the literature, with some defining it by ingested dose or serum acetaminophen concentration. The focus is on identifying mitochondrial dysfunction as part of the clinical presentation in severely poisoned patients, indicating a different scenario than common ingestions.
Presentation of Severely Poisoned Patients
In severely poisoned patients, presentation differs from typical acetaminophen overdoses, with examples like a patient presenting with a GCS of three, requiring intubation, hypothermia, and hypotension. Such cases may not fit the traditional profile of acetaminophen toxicity, necessitating a high index of suspicion.
Need for Early Treatment Initiation
In cases of massive Tylenol ingestion, early initiation of treatment, even before lab results return, is crucial. Empirically starting acetylcysteine based on clinical suspicion can prevent delays in providing necessary care to severely poisoned patients.
Specialized Laboratory Testing and NAC Dosage
Specific lab tests such as serum acetaminophen concentration, VBG, lactate, and possibly salicylate levels aid in managing massive acetaminophen ingestions. NAC dosing varies with evolving protocols, emphasizing the importance of tailoring dosages based on serum acetaminophen concentrations for optimal patient outcomes.