Downloaded from Downloaded from Downloaded from Downloaded from Downloaded from http://emj.bmj.com/ http://emj.bmj.com/ http://emj.bmj.com/ http://emj.bmj.com/ http://emj.bmj.com/ on March 6, 2016 - Published by on March 6, 2016 - Published by on March 6, 2016 - Published by on March 6, 2016 - Published by on March 6, 2016 - Published by group.bmj.com group.bmj.com group.bmj.com group.bmj.com group.bmj.com 202 ORIGINAL ARTICLE Paracetamol overdose: an evidence based flowchart to guide management C I Wallace, P I Dargan, A L Jones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emerg Med J 2002; 19 :202–205 A flowchart for the management of patients with often difficult to manage overdose. The flowchart paracetamol poisoning is presented to help clinicians in that we present will guide the clinician through the management of a patient presenting with a the emergency department. paracetamol overdose in a stepwise fashion. It can . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . also be used as an educational tool because it indicates the evidence (or lack of it) for each management step. It therefore augments the cur- P aracetamol is the commonest drug taken in 12 The flowchart is a rent NPIS paracetamol poster. overdose in the United Kingdom. While the guideline however, and not a protocol, and management of early paracetamol poisoning individual decisions will need to be made for is straightforward, the management of late every patient based on their particular circum- presenting cases, cases presenting after a stag- stances. gered overdose, and patients with risk factors for paracetamol poisoning can be much more com- plex. The authors have developed and present METHODS here an evidence based flowchart that will guide We conducted a literature search of Medline, T ox- clinicians step by step through the investigation line, and Embase using the terms “paracetamol” and treatment of all patients presenting to hospi- and “acetaminophen” with “intoxication”, “poi- tal after this common, but often difficult to man- soning” and “overdose”. No language was barred age overdose. As well as a management guideline and no other limitations were placed. The this flowchart can be used as an educational tool. retrieved abstracts were reviewed and the most pertinent articles were reviewed in more detail. In BACKGROUND addition, we took into account the consensus rec- Paracetamol is the commonest drug taken in ommendations from the UK T oxicology Group overdose in the United Kingdom, accounting for (National Poisons Information Service (NPIS), Paracetamol Information Centre, and British 48% of all poisoning admissions to hospital and 1–6 However, Association of Accident and Emergency Medi- an estimated 100–200 deaths per year. cine) on which the current UK guidelines for the junior doctors’ knowledge about the management 7 management of paracetamol poisoning are based. of paracetamol poisoning is poor. This evidence base was then used to construct an The management of patients who present early (less than 15 hours) after ingestion of a single algorithmic flowchart to guide the clinician paracetamol overdose is straightforward. If the through the management of both simple and complex paracetamol poisoning in a stepwise patient has taken a potentially toxic dose of para- fashion. cetamol, management is guided by the plasma paracetamol concentration; treatment with N-acetylcysteine in patients with a toxic plasma RESULTS paracetamol concentration provides complete protection against paracetamol induced See figure 1 for the flowchart used to guide the 8 However, when cases stray from hepatotoxicity. management of patients with paracetamol poi- this simple scenario (such as with staggered soning, together with the supporting references 8–45 overdoses, patients with high risk factors for from the literature. paracetamol poisoning, or late presentation), The paracetamol flowchart is structured 9–11 management decisions are more complex. around a few crucial branchpoints in the follow- Current guidelines for paracetamol poisoning ing order. Is the patient presenting after a single are based on the consensus recommendations of or staggered overdose? What is the time after the UK National Poisons Information Service ingestion? What are the results to the relevant (NPIS), they have also been adopted by the Royal investigations? Based upon the results of these Correspondence to: College of Paediatrics and Child Health as a Good questions, the clinician is guided through the Dr A Jones, National Poisons Information Practice Consensus Statement. The guidelines appropriate steps in investigation and treatment Service, Guy’s and St have been circulated to all accident and emer- of the paracetamol overdose. So that the flow- Thomas’ NHS Trust, gency departments in the form of a poster in chart can be used as a stand alone tool to guide Avonley Road, London, prose format and we support their use. 12 patient management we have included the stand- SE14 5ER, UK; Our aim is to provide an evidence based, easy to ard UK plasma paracetamol treatment alison.jones@ 8 12 37 together with information boxes gstt.sthames.nhs.uk follow, and visually attractive management nomogram, 13–19 guideline for paracetamol poisoning, aimed at on risk factors for paracetamol poisoning, Accepted for publication 8 40 and management of emergency and general physicians (particularly doses of N-acetylcysteine 29 October 2001 . . . . . . . . . . . . . . . . . . . . . . . 41 42 junior doctors) dealing with this common, but adverse reactions to N-acetylcysteine. www.emjonline.com
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