The patient may have vomiting, jaundice, abdominal pain, bleeding, confusion, lethargy, or even be in a coma. Stage III (72-96 hours) is called the hepatic stage. In stage II (24-48 hours), the patient may show improvement in their clinical symptoms. Sometimes they may have pallor and diaphoresis. In stage I (first 24 hours), the patient may have symptoms of anorexia, nausea, and vomiting.
There are four stages of acetaminophen overdose. In children 1 to 5 years, severe liver toxicity is rare with a single ingestion of acetaminophen, for reasons which are unclear. In severe overdoses, the glutathione stores become depleted and the toxic metabolite NAPQI builds up causing hepatocellular necrosis. However, the hepatic glutathione conjugates the NAPQI to produce APAP-mercapturate and APAP-cysteine which are both nontoxic metabolites. NAPQI is potentially toxic and may cause hepatic injury. Only a small percentage (5-15%) of the acetaminophen undergoes metabolism via the P-450 cytochrome oxidase system in the liver to produce the toxic intermediate N-acetyl-p-benzoquinoneimine (NAPQI). The majority of acetaminophen is metabolized via the sulfation and glucuronidation pathways into nontoxic products which are then excreted via the urine. Because acetaminophen is an ingredient found in many over-the-counter cold medications, it should be considered in intentional overdoses, as the patient may not realize that it is one of the components in the combination product taken.Īcetaminophen is metabolized in the liver via glucuronidation, sulfation, and through the cytochrome P-450 pathway. It is a frequent toxic ingestion in young children and adolescents. She is hospitalized for further treatment as well as a psychiatric evaluation.Īcetaminophen (N-acetyl-p-aminophenol) or APAP is a common antipyretic and analgesic medication. The acetaminophen level drawn at 8.5 hours post-ingestion is 150 mcg/mL. An acetaminophen level, aspirin level, blood and urine toxicology screen and beta-HCG are drawn.
She is also given 10 grams of N-acetylcysteine orally. She is given 50 grams of activated charcoal with sorbitol orally. She is alert, oriented, and walks about the room without difficulty. Her abdomen is soft, with normoactive bowel sounds, minimal epigastric tenderness, no rebound, and no guarding. Heart is regular with a normal rhythm and rate. She is alert, quiet, shaking her head yes/no to questions, with poor eye contact. There are 8 tablets remaining in the bottle (maximum 11 grams of acetaminophen ingested).Įxam: VS T 37.2, P 88, R 18, BP 110/70, weight 50kg. Her mother reports it was a new unopened bottle with a quantity of 30 tablets. She admits that last night she took some pills at 2100. She woke her mom up early this morning saying that she feels sick.
Her mother reports that she (the patient) had an argument with her boyfriend last night. Burns School of MedicineĪ 16 year old female presents to the emergency department at 0500 with vomiting and nausea. Case Based Pediatrics Chapter Case Based Pediatrics For Medical Students and Residentsĭepartment of Pediatrics, University of Hawaii John A.
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