Skip to main content
Emergency Medicine Journal : EMJ logoLink to Emergency Medicine Journal : EMJ
. 2002 May;19(3):202–205. doi: 10.1136/emj.19.3.202

Paracetamol overdose: an evidence based flowchart to guide management

C Wallace 1, P Dargan 1, A Jones 1
PMCID: PMC1725876  PMID: 11971827

Abstract

A flowchart for the management of patients with paracetamol poisoning is presented to help clinicians in the emergency department.

Full Text

The Full Text of this article is available as a PDF (96.0 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Agran P. F., Zenk K. E., Romansky S. G. Acute liver failure and encephalopathy in a 15-month-old infant. Am J Dis Child. 1983 Nov;137(11):1107–1114. doi: 10.1001/archpedi.1983.02140370067022. [DOI] [PubMed] [Google Scholar]
  2. Bailey B., McGuigan M. A. Management of anaphylactoid reactions to intravenous N-acetylcysteine. Ann Emerg Med. 1998 Jun;31(6):710–715. doi: 10.1016/s0196-0644(98)70229-x. [DOI] [PubMed] [Google Scholar]
  3. Bialas M. C., Reid P. G., Beck P., Lazarus J. H., Smith P. M., Scorer R. C., Routledge P. A. Changing patterns of self-poisoning in a UK health district. QJM. 1996 Dec;89(12):893–901. doi: 10.1093/qjmed/89.12.893. [DOI] [PubMed] [Google Scholar]
  4. Blantz R. C. Acetaminophen: acute and chronic effects on renal function. Am J Kidney Dis. 1996 Jul;28(1 Suppl 1):S3–S6. doi: 10.1016/s0272-6386(96)90561-2. [DOI] [PubMed] [Google Scholar]
  5. Bray G. P., Mowat C., Muir D. F., Tredger J. M., Williams R. The effect of chronic alcohol intake on prognosis and outcome in paracetamol overdose. Hum Exp Toxicol. 1991 Nov;10(6):435–438. doi: 10.1177/096032719101000612. [DOI] [PubMed] [Google Scholar]
  6. Buckley N. A., Whyte I. M., O'Connell D. L., Dawson A. H. Activated charcoal reduces the need for N-acetylcysteine treatment after acetaminophen (paracetamol) overdose. J Toxicol Clin Toxicol. 1999;37(6):753–757. doi: 10.1081/clt-100102452. [DOI] [PubMed] [Google Scholar]
  7. Buhl R., Jaffe H. A., Holroyd K. J., Wells F. B., Mastrangeli A., Saltini C., Cantin A. M., Crystal R. G. Systemic glutathione deficiency in symptom-free HIV-seropositive individuals. Lancet. 1989 Dec 2;2(8675):1294–1298. doi: 10.1016/s0140-6736(89)91909-0. [DOI] [PubMed] [Google Scholar]
  8. Dawson A. H., Henry D. A., McEwen J. Adverse reactions to N-acetylcysteine during treatment for paracetamol poisoning. Med J Aust. 1989 Mar 20;150(6):329–331. doi: 10.5694/j.1326-5377.1989.tb136496.x. [DOI] [PubMed] [Google Scholar]
  9. Douidar S. M., al-Khalil I., Habersang R. W. Severe hepatotoxicity, acute renal failure, and pancytopenia in a young child after repeated acetaminophen overdosing. Clin Pediatr (Phila) 1994 Jan;33(1):42–45. doi: 10.1177/000992289403300107. [DOI] [PubMed] [Google Scholar]
  10. Eguia L., Materson B. J. Acetaminophen-related acute renal failure without fulminant liver failure. Pharmacotherapy. 1997 Mar-Apr;17(2):363–370. [PubMed] [Google Scholar]
  11. Fagan E., Wannan G. Reducing paracetamol overdoses. BMJ. 1996 Dec 7;313(7070):1417–1418. doi: 10.1136/bmj.313.7070.1417. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Gazzard B. G., Widdop B., Davis M., Hughes R. D., Goulding R., Williams R. Early prediction of the outcome of a paracetamol overdose based on an analysis of 163 patients. Postgrad Med J. 1977 May;53(619):243–247. doi: 10.1136/pgmj.53.619.243. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Gunnell D., Hawton K., Murray V., Garnier R., Bismuth C., Fagg J., Simkin S. Use of paracetamol for suicide and non-fatal poisoning in the UK and France: are restrictions on availability justified? J Epidemiol Community Health. 1997 Apr;51(2):175–179. doi: 10.1136/jech.51.2.175. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Hardern R. D., Hampshaw S. What do accident and emergency medical staff think of practice guidelines? Eur J Emerg Med. 1997 Jun;4(2):68–71. doi: 10.1097/00063110-199706000-00003. [DOI] [PubMed] [Google Scholar]
  15. Hardern R. D., Hodgson L. C., Hamer D. W. Flow diagram or prose: does the format of practice guidelines matter? Eur J Emerg Med. 1998 Jun;5(2):241–244. [PubMed] [Google Scholar]
  16. Harrison P. M., Keays R., Bray G. P., Alexander G. J., Williams R. Improved outcome of paracetamol-induced fulminant hepatic failure by late administration of acetylcysteine. Lancet. 1990 Jun 30;335(8705):1572–1573. doi: 10.1016/0140-6736(90)91388-q. [DOI] [PubMed] [Google Scholar]
  17. Harrison P. M., O'Grady J. G., Keays R. T., Alexander G. J., Williams R. Serial prothrombin time as prognostic indicator in paracetamol induced fulminant hepatic failure. BMJ. 1990 Oct 27;301(6758):964–966. doi: 10.1136/bmj.301.6758.964. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Hawton K., Fagg J. Trends in deliberate self poisoning and self injury in Oxford, 1976-90. BMJ. 1992 May 30;304(6839):1409–1411. doi: 10.1136/bmj.304.6839.1409. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Henretig F. M., Selbst S. M., Forrest C., Kearney T. K., Orel H., Werner S., Williams T. A. Repeated acetaminophen overdosing. Causing hepatotoxicity in children. Clinical reports and literature review. Clin Pediatr (Phila) 1989 Nov;28(11):525–528. doi: 10.1177/000992288902801107. [DOI] [PubMed] [Google Scholar]
  20. Hulbert D. C., Bray G. P., Beckett M. W. The management of paracetamol overdose by junior doctors. J Accid Emerg Med. 1995 Mar;12(1):66–67. doi: 10.1136/emj.12.1.66-b. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Jones A. L. Mechanism of action and value of N-acetylcysteine in the treatment of early and late acetaminophen poisoning: a critical review. J Toxicol Clin Toxicol. 1998;36(4):277–285. doi: 10.3109/15563659809028022. [DOI] [PubMed] [Google Scholar]
  22. Keays R., Harrison P. M., Wendon J. A., Forbes A., Gove C., Alexander G. J., Williams R. Intravenous acetylcysteine in paracetamol induced fulminant hepatic failure: a prospective controlled trial. BMJ. 1991 Oct 26;303(6809):1026–1029. doi: 10.1136/bmj.303.6809.1026. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Linden C. H., Rumack B. H. Acetaminophen overdose. Emerg Med Clin North Am. 1984 Feb;2(1):103–119. [PubMed] [Google Scholar]
  24. Makin A., Williams R. The current management of paracetamol overdosage. Br J Clin Pract. 1994 May-Jun;48(3):144–148. [PubMed] [Google Scholar]
  25. Makin A., Williams R. The current management of paracetamol overdosage. Br J Clin Pract. 1994 May-Jun;48(3):144–148. [PubMed] [Google Scholar]
  26. O'Grady J. G., Wendon J., Tan K. C., Potter D., Cottam S., Cohen A. T., Gimson A. E., Williams R. Liver transplantation after paracetamol overdose. BMJ. 1991 Jul 27;303(6796):221–223. doi: 10.1136/bmj.303.6796.221. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Prescott L. F., Critchley J. A. The treatment of acetaminophen poisoning. Annu Rev Pharmacol Toxicol. 1983;23:87–101. doi: 10.1146/annurev.pa.23.040183.000511. [DOI] [PubMed] [Google Scholar]
  28. Prescott L. F., Illingworth R. N., Critchley J. A., Stewart M. J., Adam R. D., Proudfoot A. T. Intravenous N-acetylcystine: the treatment of choice for paracetamol poisoning. Br Med J. 1979 Nov 3;2(6198):1097–1100. doi: 10.1136/bmj.2.6198.1097. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Prescott L. F. Paracetamol overdosage. Pharmacological considerations and clinical management. Drugs. 1983 Mar;25(3):290–314. doi: 10.2165/00003495-198325030-00002. [DOI] [PubMed] [Google Scholar]
  30. Prescott L. F. Paracetamol, alcohol and the liver. Br J Clin Pharmacol. 2000 Apr;49(4):291–301. doi: 10.1046/j.1365-2125.2000.00167.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Prescott L. F., Proudfoot A. T., Cregeen R. J. Paracetamol-induced acute renal failure in the absence of fulminant liver damage. Br Med J (Clin Res Ed) 1982 Feb 6;284(6313):421–422. doi: 10.1136/bmj.284.6313.421-d. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Prescott L. F., Roscoe P., Wright N., Brown S. S. Plasma-paracetamol half-life and hepatic necrosis in patients with paracetamol overdosage. Lancet. 1971 Mar 13;1(7698):519–522. doi: 10.1016/s0140-6736(71)91125-1. [DOI] [PubMed] [Google Scholar]
  33. Record C. O., Iles R. A., Cohen R. D., Williams R. Acid-base and metabolic disturbances in fulminant hepatic failure. Gut. 1975 Feb;16(2):144–149. doi: 10.1136/gut.16.2.144. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Rumack B. H., Matthew H. Acetaminophen poisoning and toxicity. Pediatrics. 1975 Jun;55(6):871–876. [PubMed] [Google Scholar]
  35. Singer A. J., Carracio T. R., Mofenson H. C. The temporal profile of increased transaminase levels in patients with acetaminophen-induced liver dysfunction. Ann Emerg Med. 1995 Jul;26(1):49–53. doi: 10.1016/s0196-0644(95)70237-7. [DOI] [PubMed] [Google Scholar]
  36. Smith D. W., Isakson G., Frankel L. R., Kerner J. A., Jr Hepatic failure following ingestion of multiple doses of acetaminophen in a young child. J Pediatr Gastroenterol Nutr. 1986 Sep-Oct;5(5):822–825. doi: 10.1097/00005176-198609000-00028. [DOI] [PubMed] [Google Scholar]
  37. Smith J. A., Hine I. D., Beck P., Routledge P. A. Paracetamol toxicity: is enzyme induction important? Hum Toxicol. 1986 Dec;5(6):383–385. doi: 10.1177/096032718600500610. [DOI] [PubMed] [Google Scholar]
  38. Stone T. T., Kivlahan C. H., Cox K. R. Evaluation of physician preferences for guideline implementation. Am J Med Qual. 1999 Jul-Aug;14(4):170–177. doi: 10.1177/106286069901400404. [DOI] [PubMed] [Google Scholar]
  39. Swetnam S. M., Florman A. L. Probable acetaminophen toxicity in an 18-month-old infant due to repeated overdosing. Clin Pediatr (Phila) 1984 Feb;23(2):104–105. doi: 10.1177/000992288402300208. [DOI] [PubMed] [Google Scholar]
  40. Thomas S. H., Bevan L., Bhattacharyya S., Bramble M. G., Chew K., Connolly J., Dorani B., Han K. H., Horner J. E., Rodgers A. Presentation of poisoned patients to accident and emergency departments in the north of England. Hum Exp Toxicol. 1996 Jun;15(6):466–470. doi: 10.1177/096032719601500602. [DOI] [PubMed] [Google Scholar]
  41. Vale J. A., Proudfoot A. T. Paracetamol (acetaminophen) poisoning. Lancet. 1995 Aug 26;346(8974):547–552. doi: 10.1016/s0140-6736(95)91385-8. [DOI] [PubMed] [Google Scholar]
  42. Wendel A., Jaeschke H., Gloger M. Drug-induced lipid peroxidation in mice--II. Protection against paracetamol-induced liver necrosis by intravenous liposomally entrapped glutathione. Biochem Pharmacol. 1982 Nov 15;31(22):3601–3605. doi: 10.1016/0006-2952(82)90582-2. [DOI] [PubMed] [Google Scholar]
  43. Whitcomb D. C., Block G. D. Association of acetaminophen hepatotoxicity with fasting and ethanol use. JAMA. 1994 Dec 21;272(23):1845–1850. doi: 10.1001/jama.1994.03520230055038. [DOI] [PubMed] [Google Scholar]
  44. Wrights N., Prescott L. F. Potentiation by previous drug therapy of hepatotoxicity following paracetamol overdosage. Scott Med J. 1973 Mar;18(2):56–58. doi: 10.1177/003693307301800205. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

[Corrected Flowchart]
emermedj_19_3_202__1.pdf (30.6KB, pdf)

Articles from Emergency Medicine Journal : EMJ are provided here courtesy of BMJ Publishing Group

RESOURCES