Table 3.
Treatment and Management of APAP Overdose
| Initial Measures on Presentation |
|---|
| Within 4 hours of ingestion |
| Ipecac syrup, 15 ml once; repeat in 20 minutes if needed |
| Nasogastric lavage of pill fragments |
| Activated charcoal, 1 g/kg body weight (maximum dose 50 grams) |
| Within 16 hours of Ingestion |
| NAC, oral or intravenous |
| Oral loading: 140 mg/kg followed by 70 mg/kg every 4 hours for 17 doses or until INR < 1.5 |
| nausea and vomiting in 20%, mix with carbonated beverages to improve tolerance; prochlorperazine (Compazine) 10 mg, metoclopramide (Reglan) 10 mg, or ondansetron (Zofran) 4 mg by mouth or IV; consider IV NAC if refractory nausea and vomiting |
| Intravenous loading: 150 mg/kg in 250 ml dextrose 5% over 1 hour, then 50 mg/kg in 500 ml dextrose 5% over 4 hours; then 125 mg/kg in 1000 ml dextrose 5% over 19 hours; 100 mg/kg in 1000 ml dextrose 5% over 24 hours for 2 days or until INR is less than 1.5. Contraindicated in sulfa allergy. |
| IV NAC requires telemetry monitoring for arryhythmias and hypotension. Anaphylactoid reactions with urticaria or wheezing should have the infusion stopped and receive IM epinephrine, IV diphenhydramine, corticosteroids and albuterol. Resumption of infusion only in a monitored setting and consultation with local poison control center. If hypotension or angioedema, give fluids, steroids, and epinephrine and do not resume IV NAC (consider oral NAC with careful monitoring) |
| Minimum duration of NAC administration is 24 hours if no signs of liver injury or renal failure at 24 hours and 72 hours if evidence of liver injury. |
| IV NAC is generally preferred in pregnant women to maximize drug levels to fetus and also for individuals with short gut or ileus. |
| General Supportive Measures |
| Quiet and comfortable environment |
| Nutritional support |
| Monitoring of laboratory measures (every 12 hours) |
| Blood glucose monitoring every hour |
| Intravenous fluids if hypotension |
| Frequent screening for infection, low threshold for starting antimicrobial agents |
| Avoid correction of coagulopathy except for active bleeding or invasive procedures |
| Avoid nephrotoxic agents (NSAIDs, aminoglycosides) |
| Frequent monitoring of neurological status |
| Intensive Care |
| Urgent liver transplant evaluation |
| Encephalopathy grade I or II |
| Computed tomography of head to evaluate bleeding/cerebral edema |
| Avoid sedation; propofol and midazolam preferred for severe agitation |
| Keep head of bed > 30 degrees to avoid intracranial hypertension |
| Encephalopathy grade III or IV |
| Avoid fever; goal temperature ∼ 36°C |
| Intubation and mechanical ventilation |
| Vasopressor support if persistent hypotension despite IV fluids |
| Renal support: CVVH preferred over hemodialysis |
| Invasive monitoring of intracranial pressure, treat with hyperventilation, mannitol or hypertonic saline; barbiturate coma for refractory cases |
Abbreviations: CVVH, continuous veno‐venous hemofiltration; NSAID, nonsteroidal anti‐inflammatory drugs.