Acetaminophen Overdose (Deep Dive R24)

EM Clerkship

Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD

Health & Fitness, Science, Education, Medicine, Life Sciences

4.9 • 816 Ratings

🗓️ 16 August 2021

⏱️ 14 minutes

🔗️ Recording | iTunes | RSS

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Summary

Acetaminophen Overdose & Toxicology Pearls

* History: Figure out how much was taken, what time the ingestion occurred, and if any other toxins were ingested* Physical Exam: Perform a regular physical exam, and in addition, perform the toxicologic physical exam!* Check pupil size* Assess neuromuscular status for rigidity/clonus* Perform the “toxicologist handshake”* Listen to bowel sounds* Workup:* Accucheck* ECG* CBC, CMP, VBG* Acetaminophen Level (now and at four hours); Salicylate Level* UDS* Consider specific drug levels (eg digoxin, lithium, valproic acid, etc) ; consider ammonia level for valproic acid OD* Management:* ABCs first* Consider decontamination (remove clothes, hose down with water if chemical exposure, consider activated charcoal or gastric lavage for early ingestions)* Consult poison control/toxicology* Consult psychiatry if it was an attempt at self harm* Administer NAC if considered to be a “toxic ingestion of acetaminophen”* Definition of an “Acetaminophen Toxic Ingestion”* Single ingestion of acetaminophen greater than 150mg/kg* Data point on Rumack-Matthew Nomogram that is above the treatment line* If UNKNOWN amount / UNKNOWN timing of ingestion, treat if LFTs are elevated or if serum acetaminophen level is above normal limits* Rule of 150* Toxic Ingestion is considered to be a single ingestion greater than 150mg/kg* Toxic Ingestion is considered to be if the acetaminophen level at the four hour mark is >150ug/mL (this would be above the treatment line on the Rumack-Matthew Nomogrom)* Dose of NAC is 150mg/kg IV

Further Reading:

Rumack-Matthew Nomogram (MDCalc)

Transcript

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0:00.0	Hello, students. My name is Mike Estefan, and I thank you for joining me today on this
0:06.2	month's deep dive episode on the EM Clerkship podcast. Today's episode is going to be covering
0:13.1	acetaminopin overdose, as well as a general approach to the toxicology physical exam.
0:18.9	Before we begin the content, I have two important things I need to tell
0:22.9	you guys about. The first is regarding our recent string of technical difficulties. In the span of the last
0:29.3	two, two and a half weeks, our website has crashed twice, and we've also been hacked. Like, what the
0:34.6	heck? Who hacks EM clerkship? Anyways, all of this nonsense have resulted in
0:41.5	multiple delays in the release of our content, which usually occur on the first and the 15th of
0:46.7	every month. So, as of today, everything should be functioning normally at this time.
0:53.2	However, you may come across some strange
0:55.7	advertisements if you try to Google our website. We are working with Google to remove these search
1:01.3	results, but it could take some time, so please bear with us. The second thing I want to discuss
1:06.6	is just a word from our sponsors, Pearson Rabbit's disability insurance. I know we keep belaboring
1:12.3	this point, but own occupation disability insurance is incredibly important. In fact, just last
1:19.0	week, I was reviewing my significant others disability insurance policy. She works as a physician
1:24.6	in pediatric gastroenterology, which is somewhat of a procedurally
1:28.7	heavy subspecialty.
1:30.7	We discovered that the disability insurance that she had signed up for as a resident did
1:35.8	not include own occupation disability.
1:39.3	What this means practically is that if she were to become injured to the point where she
1:43.6	could no longer perform
1:44.7	procedures such as endoscopies and colonoscopies, her disability insurance would likely not
	...

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