We have an update on the Management of Paracetamol Poisonings (MJA 203(5). 7 September 2015) (last update was in 2008) and it covers six main areas:
- Risk Assessment
- Charcoal Use
- Modified Release Paracetamol
- Large/Massive Ingestions
- Liquid paracetamol in children less than 6 years old.
- Consulting a Liver Transplant Unit
Some Notes:
- In children less than 6 years old, use ideal weight
- In children greater than 6 years old and in adults use actual weights to a maximum of 110kg
- Large doses are greater than 30g paracetamol
- Doses greater than 50g should be discussed with a toxicologist
- These guidelines apply to oral paracetamol- advice from toxicologist needed in IV paracetamol
RISK ASSESSMENT
|
DOSE |
CHILDREN < 6yo |
CHILDREN > 6yo and ADULTS
|
|
Single dose over a period of <8 hours |
>200mg/kg |
>200mg/kg or 10g (which ever is lower) |
|
Repeated SUPRATHERAPEUTIC ingestion |
> 200mg/kg over a 24 hour period |
>200mg/kg or 10g (which ever is lower) over 24 hour period |
|
>150mg/kg per 24 hour period for preceding 48 hours |
>150mg/kg or 6g (which ever is lower) per 24 hour period for preceding 48 hours |
|
|
>100mg/kg per 24 hour period for more than 24 hours |
>100mg/kg or 4g/day (which ever is lower) per 24 hour period for more than 24 hours in those with symptoms of liver injury: abdo pain, nausea and vomiting |
PARACETAMOL DOSING ASSOCIATED WITH HEPATIC INJURY
CHARCOAL USE
Single Dose Immediate release
- 50g of charcoal can be given up to 2 hours post ingestion
- If paracetamol dose is > 30g give charcoal up to 4 hours post ingestion
Modified release Paracetamol (i.e. panadol osteo)
- Can administer charcoal up to 4 hours post ingestion
- If paracetamol dose taken is >30g can benefit from charcoal at > 4hours post ingestion
MODIFIED RELEASE PARACETAMOL
As in the previous guideline treatment start Acetylceistine if > 200mg/kg or 10g has been ingested, given that two assessments of paracetamol concentration must be made 4 hours apart(the first being 4 hours post ingestion)
What has changed is when to discontinue acetylcysteine infusion
- paracetamol concentrations 4 hours apart must be below nomogram and decreasing
- continue infusion if ALT >50U/L or paracetamol is >10mg/L(66umol/L)
LARGE/MASSIVE INGESTIONS
- In those that ingest > 30g paracetamol, if the paracetamol level is twice the nomogram line, then double the concentration of the 16 hour infusion(no randomised control trials)
- Continue if at near completion of the 16 hour protocol the ALT>50U/L or paracetamol levels are >10mg/L or 66umol/L
LIQUID PARACETAMOL IN CHILDREN < 6 YEARS OLD
This only applies to well children who present at less than 4 hours post ingestion
CONSULTING A LIVER TRANSPLANT UNIT
The following criteria need to be met:
- INR >3 at 48 hours of >4.5 at any time
- Oliguria or Creatinine > 200umol/L
- Persistent acidosis pH<7.3 or lactate >3mmol/L
- Systolic BP < 80mmHg despite resuscitation
- Hypoglycaemia
- Severe thrombocytopenia
- Encephalopathy
