College of Nursing

West Avenue, Molo, Iloilo City

ILOILO DOCTORS’ COLLEGE

NCM 118 (RLE)

Care of Clients with Life-Threatening Conditions, Acutely Ill/ Multi-Organ
Problems, High Acuity and Emergency Situations

Case Scenario No. 11

Acetaminophen Poisoning
Introduction

Acetaminophen is one of the most common medications found in households. It is used

for the treatment of pain and to lower fever. Over many years, it has been used countless times
by many people, and it has proven to be a safe and effective medication. However, if taken in
excess amounts (overdose, whether on purpose or by accident), acetaminophen can cause life-
threatening illness. Unless otherwise directed by your care provider, the usual maximum
recommended dose is 3 grams in 24 hours. Acetaminophen is the active ingredient in Tylenol. It
is also found in many other over-the-counter medications and in prescription drugs.

Acetaminophen in overdose can seriously damage the liver. If the damage is severe,

a liver transplant may be necessary in order to save someone’s life. The antidote to
acetaminophen overdose is N-acetylcysteine (NAC). It is most effective when given within eight
hours of ingesting acetaminophen. Indeed, NAC can prevent liver failure if given early enough.
For this reason, it is absolutely necessary that acetaminophen poisoning be recognized,
diagnosed, and treated as early as possible. (WebMD, 2021) In adults, an acute ingestion of more
than 150 mg/kg or 12 g of acetaminophen is considered a toxic dose and poses a high risk of
liver damage. In children, acute ingestion of 250 mg/kg or more poses significant risk for
acetaminophen-induced hepatotoxicity. (Medscape, 2021)

Acetaminophen toxicity is the second most common cause of liver transplantation

worldwide and the most common cause of liver transplantation in the US. It is responsible for
56,000 emergency department visits, 2,600 hospitalizations, and 500 deaths per year in the
United States. Fifty percent of these are unintentional overdoses. More than 60 million
Americans consume acetaminophen on a weekly basis, and many are unaware that it is contained
in combined products.

General Objectives:
At the end of the case study, the students will be able to:
To acquire knowledge about Acetaminophen Poisoning and be able to provide specific nursing
interventions for the patient.
Knowledge:
● Define Acetaminophen Poisoning
● Explain the anatomy and physiology of the affected organ.
● Discuss the pathophysiology of the disease.

Skills:
● Perform a comprehensive assessment of the patient and her condition
● Formulate an effective and efficient nursing care plan for patients with Acetaminophen
Poisoning
● Develop an appropriate discharge plan for the patient.

Attitude:
● Establish rapport with the patient and family.
● Empathize with the patient and family
● Respond to the needs of the patient

II. Patient’s Data

Fiona 20 months old, weighs 14kgs, residing in Timawa, Iloilo City was left alone by her mom
Mrs. Lila in her crib as she was busy doing her household chores. She is a typical 2-year-old,
who climb stairs, chairs, and loved to be chased by cousins when awake. She can speak a few
words like Mama, Papa, drink, eat, cat, dog to mention. She is bottle feed with Bonna Kid and
eats anything given to her but manifest temper tantrums when her demands are not attended. By
11 am when Mrs. Lila checked on her she found out that Fiona climb out of her crib and took
around 6 tablets of Acetaminophen (Tylenol) out of curiosity. Fiona climbed the table nearby
and reached the bottle as she thought it is candy. Mrs. Lila found her on generalized tonic clonic
convulsion for 1 minute. She appeared, confused, vomits and diaphoretic lying next to the bottle
a few hours later. The ICER brought them to the ER of the nearest hospital.

On examination Fiona’s T=38.5 degree Celsius, PR= 60 bpm, is irregular, RR= 20 cpm and B/P
= 90/60 mmHg.O2 saturation=95%. The child was sleepy and weak. The pupils were 1 mm in
diameter and not reactive to light. The cardiovascular, respiratory and abdominal examinations
were unremarkable. The neck was soft and Babinski response was negative bilaterally. The
bedside blood sugar level was 1.8 mmol/L. The X-ray chest was normal. She starts to cry and
regain consciousness after 4 hours. She vomited approximately 30 ml of whitish secretions with
some particles of Acetaminophen. Fiona was placed on NPO temporarily. Mother looked
anxious and cried during history taking, feeling guilty of what happened.
III. Past and Present History
Past History
Fiona, 20 months old, weighs 14kgs, residing in Timawa, Iloilo City was left alone by her mom
Mrs. Lila in her crib as she was busy doing her household chores. She is a typical 2-year-old,
who climbs stairs, chairs, and loves to be chased by cousins when awake. She can speak a few
words like Mama, Papa, drink, eat, cat, dog to mention. She is bottle fed with Bonna Kid and
eats anything given to her but manifests temper tantrums when her demands are not attended to.
By 11 am when Mrs. Lila checked on her, she found out that Fiona climbed out of her crib and
took around 6 tablets of Acetaminophen (Tylenol) out of curiosity. Fiona climbed the table
nearby and reached the bottle as she thought it was candy. Mrs. Lila found her on generalized
tonic clonic convulsion for 1 minute. She appeared, confused, vomiting and diaphoretic lying
next to the bottle a few hours later.
Present History
The ICER brought them to the ER of the nearest hospital. Upon admission, Fiona’s temperature
is 38.5C, pulse rate of 60 bpm, respiratory rate of 20 cpm and blood pressure of 90/60 mmHg
with 95% oxygen saturation. D5IMB 500 ml x 25 ml/ H was started. NGT insertion done and
Activated Charcoal was administered through gastric lavage until return flow is clear.
Paracetamol 100 mg IVTT was given as a stat dose.
The child was sleepy and weak. The pupils were 1 mm in diameter and not reactive to light. The
cardiovascular, respiratory and abdominal examinations were unremarkable. The neck was soft
and Babinski's response was negative bilaterally. The bedside blood sugar level was 1.8 mmol/L.
Intravenous dextrose was given in the form of D10 but her clinical response was poor and she
remained sleepy after 30 ml of D10. She starts to cry and regain consciousness after 4 hours. She
vomited approximately 30 ml of whitish secretions with some particles of Acetaminophen. Fiona
was placed on NPO temporarily.
Blood tests including complete blood picture, renal function, liver function, prothrombin time,
activated partial thromboplastin time, blood culture, and blood gas analysis, were performed.
Metabolic workup including organic acid, carnitine, lactate, pyruvate, and amino acid profile
were also performed. Initial liver indices, complete blood count, electrolytes and renal function
tests were normal.
After stabilizing her condition, she was transferred to PICU for further treatment and monitoring.
She was assessed regularly for further signs of Acetaminophen toxicity, NVS monitored hourly,
urine and stool output especially the stool color every shift is monitored. Bleeding not noted.
Subsequent ABG and Acetylcysteine levels are normal. The following day Milk formula was
resumed as the patient was stable and crying for milk. Course in the ward is uneventful and
discharged after 5 days of hospitalization to continue her milk formula, and Multivitamin 1 tsp
OD. Mother and significant others counselled prior to discharge.
IV. Anatomy and Physiology
Gastrointestinal System

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral
cavity, where food enters the mouth, continuing through the pharynx, esophagus, stomach and
intestines to the rectum and anus.

The main function of the GI tract is to make ingested nutrients available for the body to use.
There are five main processes involved in the functioning of the GI tract; ingestion, propulsion,
digestion, absorption and elimination. The GI tract is within the abdominal cavity. The thoracic
cavity is separated from the abdominal cavity by the diaphragm. The abdominal cavity contains
the stomach, small and large intestine, gall bladder, pancreas, and liver, and other organs such
as the spleen.

The major target organ acetaminophen toxicity is the liver. This is because acetaminophen is
metabolized in the liver.

Liver

Liver is a cone shape, dark reddish-brown organ that weighs about 3 pounds. It is the largest
solid organ and the largest gland in the human body located under your rib cage on the right
side of your abdomen. The liver is essential for digesting food and ridding your body of toxic
substances.

The liver is separated into a right and left lobe. It is located in the upper right-hand portion of the
abdominal cavity, beneath the diaphragm, and on top of the stomach, right kidney, and
intestines. The liver holds about one pint (473ml or 13%) of the body's blood supply. The liver
consists of 2 main lobes. Both are made up of 8 segments that consist of 1,000 lobules (small
lobes). These lobules are connected to small ducts (tubes) that connect with larger ducts to
form the common hepatic duct. The common hepatic duct transports the bile made by the liver
cells to the gallbladder and duodenum (the first part of the small intestine) via the common bile
duct.

There are many functions of the liver but the main one is to process the nutrients absorbed from
the small intestine. Additionally:

● Metabolism of drugs and hormones—oxidation (change due to addition of oxygen),

conjugation, and elimination through secretion of bile or via the kidneys

● Detoxification of micro-organisms and toxic substances that have been absorbed from
the gut to stop transfer to the general blood circulation

● Storage of minerals, vitamin B12, and the fat-soluble vitamins A, D, E, and K

When the liver has broken down harmful substances, its by-products are excreted into the bile
or blood. Bile by-products enter the intestine and leave the body in the form of feces. Blood by-
products are filtered out by the kidneys, and leave the body in the form of urine.
 First 24 hours after ingestion:
● Anorexia
● Nausea
● Vomiting
● Diaphoresis
● Malaise

1-2 days after ingestion:

● Hepatic damage
● Right upper quadrant pain
● Abnormally elevated liver function tests
● Abnormal blood chemistry

3-5 days after ingestion:

● Increasing signs of liver damage

● About 10% die of hepatic failure

Respiratory System

The organs of the respiratory system include the nose, pharynx, larynx, trachea, bronchi, and
their smaller branches, and the lungs, which contain the alveoli.

The upper respiratory system, or upper respiratory tract, consists of the nose and nasal cavity,
the pharynx, and the larynx. These structures allow us to breathe and speak. They warm and
clean the air we inhale: mucous membranes lining upper respiratory structures trap some
foreign particles.

The lower respiratory system, or lower respiratory tract, consists of the trachea, the bronchi and
bronchioles, and the alveoli, which make up the lungs. These structures pull in air from the
upper respiratory system, absorb the oxygen, and release carbon dioxide in exchange. Other
structures, namely the thoracic cage (or rib cage) and the diaphragm, protect and support these
functions.

The functions of the respiratory system are:

● Oxygen supplier. The job of the respiratory system is to keep the body constantly
supplied with oxygen.
● Elimination. Elimination of carbon dioxide.
● Gas exchange. The respiratory system organs oversee the gas exchanges that occur
between the blood and the external environment.
● Passageway. Passageways that allow air to reach the lungs.
● Humidifier. Purify, humidify, and warm incoming air.

Respiratory Symptoms:

● Bradypnea

Cardiovascular System
The cardiovascular system, or the Circulatory System transports nutrients and oxygen-rich
blood to all parts of the body. It consists of the heart, arteries, veins, and capillaries.

The Heart

The heart is a muscular organ that pumps blood through the network of arteries and veins. It is
located between the lungs in the middle of the chest It roughly measures the size of a closed
fist. 

Layers of the Heart

Epicardium. The outermost layer of the heart

Myocardium. The muscle layer of the heart
Endocardium. The innermost layer of the heart.

Parts

The right atrium receives non-oxygenated blood from the body’s largest veins — superior vena
cava and inferior vena cava — and pumps it through the tricuspid valve to the right ventricle.
The right ventricle pumps the blood through the pulmonary valve to the lungs, where it
becomes oxygenated.
The left atrium receives oxygenated blood from the lungs and pumps it through the mitral valve
to the left ventricle.
The left ventricle pumps oxygen-rich blood through the aortic valve to the aorta and the rest of
the body.

The heart is enclosed within a fluid-filled sac called the pericardium, a protective covering that
produces fluid, which lubricates the heart and prevents friction between the heart and the
surrounding organs.

Cardiovascular Symptoms:

● Tachycardia
● Hypotension
● Arterial Ph less than 7.30

Nervous System

The nervous system is a complex network of nerves and nerve cells (neurons) that carry signals
or messages to and from the brain and spinal cord to different parts of the body. It is made up of
the central nervous system and the peripheral nervous system.

The central nervous system (CNS) is made up of the brain and spinal cord. The brain controls
most body functions, including awareness, movements, sensations, thoughts, speech and
memory. The spinal cord is connected to the brain at the brain stem and is covered by the
vertebrae of the spine. Nerves exit the spinal cord to both sides of the body. The spinal cord
carries signals back and forth between the brain and the nerves in the rest of the body.
The central nervous system CNS is responsible for integrating sensory information and
responding accordingly. It consists of two main components; the brain is responsible for
integrating most sensory information and coordinating body function, both consciously and
unconsciously. Complex functions such as thinking and feeling as well as regulation of
homeostasis are attributable to different parts of the brain. The spinal cord serves as a conduit
for signals between the brain and the rest of the body. It also controls simple musculoskeletal
reflexes without input from the brain.

The peripheral nervous system (PNS), the part of the nervous system outside the CNS, consists
mainly of the nerves that extend from the brain and spinal cord.

Functions of the Nervous System

● Monitor changes. Much like a sentry, it uses its millions of sensory receptors to monitor
changes occurring both inside and outside the body; these changes are called stimuli,
and the gathered information is called sensory input.
● Interpret sensory input. It processes and interprets the sensory input and decides what
should be done at each moment, a process called integration.
● Effects responses. It then effects a response by activating muscles or glands
(effectors) via motor output.
● Mental activity. The brain is the center of mental activity, including consciousness,
thinking, and memory.
● Homeostasis. This function depends on the ability of the nervous system to detect,
interpret, and respond to changes in the internal and external conditions. It can help
stimulate or inhibit the activities of other systems to help maintain a constant internal
environment.

CNS Symptoms:

● Convulsions
● Generalized weakness
● Bilateral miosis
● Coma

VI. Laboratory and Diagnostic Result

LABORATORY RESULTS NORMAL SIGNIFICANCE

TEST VALUES

Total Bilirubin level 20.4 umo/L 3-7 umol/L ELEVATED Higher than
normal levels of
bilirubin may
indicate different
types of liver or
bile duct problems.
Occasionally,
higher bilirubin
 levels may be
caused by an
increased rate of
destruction of red
blood cells

Glucose level 5.7 mmol/L 4-8 mmol/L NORMAL NORMAL

Albumin level 33 g/L 32-45 g/L NORMAL NORMAL

Complete Blood - - NORMAL NORMAL

Count

Electrolyte - - NORMAL NORMAL

Renal Function Test - - NORMAL NORMAL

Prothrombin Time - - NORMAL NORMAL

Activated Partial - - NORMAL NORMAL

Thromboplastin Time

Aspartate > 3,000 U/L 8- 33 U/L ELEVATED High levels of

Transaminase AST in the blood
may indicate
hepatitis, cirrhosis,
mononucleosis, or
other liver
diseases. High
AST levels can
also indicate heart
problems or
pancreatitis.

Alanine > 2,253 U/L 4- 36 U/L ELEVATED High levels of

Transaminase ALT may indicate
liver damage from
hepatitis, infection,
cirrhosis, liver
cancer, or other
liver diseases.
Other factors,
 including
medicines, can
affect your results.

International > 3.0 1.1 and below ELEVATED When the INR is
normalised ratio higher than the
recommended
range, it means
that your blood
clots more slowly
than desired

ABG pH 7.30 7.35 - 7.45 LOW A lower pH means

that your blood is
more acidic, while
a higher pH means
that your blood is
more basic.

HCO3 18mEq/L 22-26 mEq/L LOW A low level of

bicarbonate in your
blood may cause a
condition called
metabolic acidosis,
or too much acid in
the body.

● Toxicology screen showed that the paracetamol level was 556 µmol/L at 8-hour.

N- acetylcysteine (Mucumyst) was initiated via IV

● Urine toxicology tests revealed the presence of benzodiazepine, mefenamic acid,

chlorpheniramine, methadone, normethadone and ephedrine.

This medication was present in the urine as this was accidentally ingested by the
patient
 VII. Discharge Plan

DISCHARGE PLAN
Patient Education
● Counsel patients to avoid acetaminophen (Tylenol, others) or other forms of acetaminophen,
particularly if using combination product(s) containing acetaminophen.
● Educate parents/caregivers during well-child visits.
● Anticipatory guidance for caregivers, family, and cohabitants of potentially suicidal patients
● Educate patients on long-term acetaminophen therapy.

Safety: Poisoning prevention

Poisoning can happen to anyone, anywhere, but children are particularly at risk as they enjoy
exploring and putting things in their mouth as part of their normal development. Poisoning is
most common in children aged five years and under, with those aged between one and three
years at greatest risk.
Parents and caregivers are often surprised just how many potentially poisonous substances they
have at home and the speed with which their child can touch, inhale or ingest something.
You can reduce the risk of accidental poisoning by securely storing and safely using medications
and poisonous substances.
Death from poisoning is rare, but poisoning will require emergency treatment and hospital
admission in severe cases.
First aid for poisoning
● Call an ambulance immediately if your child collapses, stops breathing or has difficulty
breathing, or is having a fit.
● If you suspect a child has been exposed to poison, do not try to induce vomiting. Do not
wait for symptoms to occur. Take the child and the container with you to the phone
immediately and call the Poisons Information Centre on 13 11 26 (24 hours a day in
Australia). They will be able to give you first aid advice. It is helpful to know what the
substance was and how much of the substance was taken.
● Do not ring the Poisons Information Centre in a medical emergency.
Preventing poisoning
● Storing chemicals
● Store chemicals, medicines and cleaning products in a locked or child-resistant cupboard,
out of reach and out of sight of children (at least 1.5 m high). Put them away immediately
after using or buying them. Locks and lockable cabinets are available at hardware stores.
● Garden sprays, fertilisers, paints, thinners and other hardware products should be kept in
a locked cupboard in a garage or shed and out of reach of children.
 ● Leave all chemicals, medicines and cleaning products in their original containers with
clear labels and ensure the lids are secured. Always follow the directions for use on the
label. Never transfer or store these products in cups or soft drink bottles.
● Store poisons away from food.
Medicines
● Refer to medicines by their proper names. Do not confuse children by referring to
medicines as lollies.
● Young children tend to imitate adults, so adults should avoid taking medicines with
children present.
● Clean medicine cupboards out regularly. Take unwanted and out-of-date medicines to a
pharmacy for disposal.
● Visitor’s bags may contain medicines. Make sure these are kept well out of reach of
children.
● Taking more than the recommended dose can be harmful, so take extra care when
measuring and giving medicines.

Seek care immediately if:

● You or another person took too much acetaminophen.
● You feel confused or more tired than usual, or you are sweating more than usual.
● You have severe nausea and are vomiting.
● You cannot have a bowel movement or urinate.
● Your skin and the whites of your eyes turn yellow.

Contact your healthcare provider if:

● You have a fever.
● You have taken too much acetaminophen by mistake, even if you do not have any signs
or symptoms.
● You have pain in the upper right side of your abdomen.
● You have questions or concerns about your condition or care.

Key points to remember

● Install child-resistant locks on all cupboards where you keep chemicals, medicines and
cleaning products.
● Leave all chemicals, medicines and cleaning products in their original containers with
their lids secured and follow the directions on the label.
● Put all chemicals away immediately after use.
● In a medical emergency, call for an ambulance.
● If you think your child has swallowed something poisonous, take the container and the
child to the phone immediately and call emergency hotline.
VIII. Review of Related Literature
 Acetaminophen (N-acetyl-para-aminophenol, paracetamol, APAP) toxicity is common primarily
because the medication is so readily available, and there is a perception that it is very safe. More than 60
million Americans consume acetaminophen on a weekly basis. Acetaminophen is used in many products
in combination with other preparations, especially with opioids and diphenhydramine. Many people are
not aware that it is contained in these combination medications.
Acetaminophen is a non-steroidal anti-inflammatory drug (NSAID), with a mechanism of action
different from other NSAIDs. Its mode of action is not clearly understood, but it appears to inhibit
cyclooxygenase (COX) in the brain selectively. This results in its ability to treat fever and pain. It may
also inhibit prostaglandin synthesis in the central nervous system (CNS). Acetaminophen directly acts on
the hypothalamus producing an antipyretic effect.
Even though acetaminophen has a good safety profile at therapeutic levels, it can cause severe
liver toxicity if taken in large amounts. The recommended dose of acetaminophen for adults is 650 mg to
1000 mg every 4 to 6 hours, not to exceed 4 grams/day. In children, the dose is 15 mg/kg every 6 hours,
up to 60 mg/kg/day. Toxicity develops at 7.5 g/day to 10 g/day or 140 mg/kg.
Acetaminophen toxicity is the second most common cause of liver transplantation worldwide and
the most common in the US. It is responsible for 56,000 emergency department visits, 2600
hospitalizations, and 500 deaths per year in the United States. Fifty percent of these are unintentional
overdoses.
Although acetaminophen poisoning is more common in children, adults often present with a more serious
and fatal presentation.
Acetaminophen is rapidly absorbed from the gastrointestinal (GI) tract and reaches therapeutic levels in
30 minutes to 2 hours. Overdose levels peak at 4 hours unless other factors could delay gastric emptying,
such as a co-ingestion of an agent that slows gastric motility, or if the acetaminophen is in an extended-
release form.
Acetaminophen has an elimination half-life of 2 hours, but can be as long as 17 hours in patients with
hepatic dysfunction. It is metabolized by the liver, where it is conjugated to nontoxic, water-soluble
metabolites that are excreted in the urine.
The diagnosis of acetaminophen toxicity is based on serum levels of the drug, even if there are no
symptoms. Other laboratory studies needed include liver function tests (LFTs) and coagulation profile
(PT/INR). If the ingestion is severe, LFTs can rise within 8 to 12 hours of ingestion. Normally LFTS
remain elevated in the second stage at 18 to 72 hours. Co-ingestions can be important, and a urine drug
screen, EKG, and a metabolic panel may be useful. If serum levels fall into the toxic range based on the
Rumack-Matthew Nomogram, then treatment should be initiated. A level greater than 140 mcg/mL at 4
hours from ingestion is considered toxic. Serum levels must be drawn between 4 to 24 hours from the
time of ingestion to use the nomogram properly. It can also only be applied to single acute ingestion.
For chronic acetaminophen ingestions, the Rumack-Matthew Nomogram cannot be applied.
Acetaminophen levels do not correlate well with the degree of overdose. In these cases, the provider must
use risk factors, lab values, and clinical suspicion to determine whether or not there was significant
ingestion. Suspect and treat an overdose if the acetaminophen level is greater than 20 mcg/mL or if LFTs
are elevated. There is usually less toxicity as the liver can regenerate its glutathione stores.
The treatment of acetaminophen poisoning depends on when the drug was ingested. If the patient
presents within 1 hour of ingestion, GI decontamination may be attempted. In alert patients, activated
charcoal can be used. Orogastric lavage or whole bowel irrigation is not effective.
 All patients with high levels of acetaminophen need admission and treatment with N-acetyl-
cysteine (NAC). This agent is fully protective against liver toxicity if given within 8 hours after ingestion.
NAC works through multiple routes. It prevents the binding of NAPQI to hepatic macromolecules, acts as
a substitute for glutathione, is a precursor for sulfate, and reduces NAPQI back to acetaminophen.
Indications for NAC include serum levels that fall in the toxic range according to the Rumack-Matthew
nomogram, an APAP level greater than 10 mcg/mL with an unknown time of ingestion, a dose of
acetaminophen greater than 140 mg/kg taken more than 8 hours ago, abnormal labs with ingestion more
than 24 hours ago, and ingestion with any evidence of liver injury.
NAC can be administered both intravenously (IV) and orally. The IV form has shown to decrease
the length of the hospital stay and may be better tolerated by the patient as the oral form has a foul rotten
egg odor and taste. The oral form also requires 18 doses given 4 hours apart, with the total treatment time
being 72 hours. In comparison, the IV form requires only 20 hours of treatment. The IV form also is
preferred in pregnant patients and when there is a fulminant hepatic failure.
Patients who continue to have deterioration such as renal failure, metabolic acidosis,
encephalopathy, and coagulopathy should have a referral to a transplant surgeon. In patients who present
24 hours after the ingestion of acetaminophen, NAC administration should still be attempted and may
improve survival. At this stage, it can act as an antioxidant that diminishes hepatic necrosis, decreases
neutrophil infiltration, improves microcirculatory blood flow, and increases tissue oxygen delivery.
Hemodialysis can also be an effective treatment, especially with concurrent renal failure.
There is no need to adjust the dose for patients with alcoholism or the chronically ill, and it is safe
in pregnancy.
NAC should be continued past 72 hours if there is a fulminant hepatic failure until the patient receives a
liver transplant, recovers, or dies.

Prognosis
If the patient is diagnosed and treated promptly, the mortality for acetaminophen toxicity is less
than 2%. However, if patients present late and have developed severe liver failure, the mortality is high.
About 1% to 3% of patients with severe liver failure need to undergo a liver transplant as a life-saving
measure.
In general, children less than 6 years of age have a better prognosis than adults, chiefly because of
their greater capacity to detoxify APAP. The overall prognosis of patients depends on the following
criteria: Creatinine levels more than 3.4 mg/dL, Arterial pH remaining less than 7.3 despite adequate fluid
hydration, Prothrombin time more than 1.8 times control or an INR of more than 6.5, Development of
grade 3 or 4 encephalopathy.
Complications
Acetaminophen can cause dangerous skin reactions. These include Stevens-Johnson syndrome
(SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). These
conditions are extremely painful and can lead to blindness and death. Acetaminophen can lead to acute
liver failure, which may only be treated with an emergent liver transplant.
In general, all drug toxicities are managed with an interprofessional team of healthcare
professionals. Besides physicians, the role of the nurse and pharmacist cannot be overstated. The nurse
and pharmacist are key players in educating the family about the potential toxicity of acetaminophen. The
parents should be informed that acetaminophen must be placed out of reach of children. In addition, the
parents have to know the proper dosing for children and appreciate the fact that there are pediatric and
adult doses of the drug. When patients are discharged, they should be provided with clear instructions on
drug dosage, frequency, and route of administration. All parents should be educated on reading the label
of the vial containing the medication. Finally, parents need to be educated that combining drugs can also
increase the risk of toxicity and this practice should be avoided.

Reference:
Agrawal S, Khazaeni B. Acetaminophen Toxicity. [2021 Jul 18]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK441917/.