Acetaminophen OD

Presentation

  • In acute OD acidosis and elevated INR can precede transaminitis
  • At very high levels acts as mitochondrial poison and inhibits oxidative phosphorylation -> acidosis – this problem not solved by NAC

Workup

  • Might need 10 hr level for extended release formulations

Treatment

  • Activated charcoal
  • No benefit of NAC prior to 4 hrs, probably doesn’t even matter as long as it’s on within 8 hrs of ingestion
  • Start NAC for:
    • any level over R-M nomogram
    • Unknown TOI w/ any detectable APAP or elevated transaminitis
    • Ingestion of >10g or 200 mg/kg
  • Can be dialyzed in the case of massive overdose causing mitochondrial poisoning and that is at high risk for death despite NAC
    • e.g. any level >600-900 and evidence of mitochondrial dysfunction (e.g. elevated lactate and acidosis) or sustained high level and worsening despite NAC