A 29-year old male presents to the emergency department 1h after an overdose of cocodamol. He admits to taking approximately 60 x 8/500mg tablets, with alcohol, over a 20 minute period. He has a past history of depression, treated by his GP with citalopram 20mg OD. He has no previous history of deliberate self-harm. His past medical history is otherwise unremarkable and he is not on any additional medications. He drinks approximately 40 units of alcohol per week. Physical examination is unremarkable, his pupils are normal diameter and his Glasgow Coma Scale is 15. He weighs 82kg.
Thummel KE, Slattery JT, Nelson SD. Mechanism by which ethanol diminishes the hepatotoxicity of acetaminophen. J Pharmacol Exp Ther. 1988; 245: 129-36.
Zimmerman, HJ, Maddrey, WC. Acetaminophen (paracetamol) hepatotoxicity with regular intake of alcohol: Analysis of instances of therapeutic misadventure. Hepatology. 1995; 22: 767-73.
Makin, AJ, Wendon, J, Williams, R. A 7-year experience of severe acetaminophen-induced hepatotoxicity (1987-1993). Gastroenterology. 1995; 109: 1907-16.
Smilkstein, MJ. Chronic ethanol use and acute acetaminophen overdose toxicity. J Toxicol Clin Toxicol. 1998; 36: 476.
Prescott, LF. Paracetamol, alcohol and the liver. Br J Clin Pharmacol. 2000; 49: 291-301.
Zimmerman, HJ, Maddrey, WC. Acetaminophen (paracetamol) hepatotoxicity with regular intake of alcohol: Analysis of instances of therapeutic misadventure. Hepatology. 1995; 22: 767-73.
Wood, DM, Dargan, PI, et al. AL. Measuring plasma salicylate concentrations in all patients with drug overdose or altered consciousness: is it necessary? Emerg Med J. 2005; 22: 401–403.
Prescott, LF, Illingworth, et al. Intravenous N-acetylcystine: the treatment of choice for paracetamol poisoning. Br Med J. 1979; 2: 1097-1100.
Beer, C, Pakravan, N, Hudson, M, et al. Liver unit admission following paracetamol overdose with concentrations below current UK treatment thresholds. QJM. 2007; 100(2): 93-6.
Prescott, LF. Treatment of severe acetaminophen poisoning with intravenous acetylcysteine. Arch Intern Med. 1981; 141: 386-9.
Waring, WS, Stephen, et al. Lower incidence of anaphylactoid reactions to N-acetylcysteine in patients with high acetaminophen concentrations after overdose. Clin Toxicol (Phila). 2008; 46(6): 496-500.
Bailey, B, McGuigan, MA. Management of anaphylactoid reactions to intravenous N-acetylcysteine. Ann Emerg Med. 1998; 31: 710-715.
Schwartz, EA, Hayes, BD, Sarmiento, KF. Development of Hepatic Failure Despite Use of Intravenous Acetylcysteine After a Massive Ingestion of Acetaminophen and Diphenhydramine. Ann Emerg Med. 2008;54(3): 421-3.
Smith, SW, Howland, et al. LS. Acetaminophen overdose with altered acetaminophen pharmacokinetics and hepatotoxicity associated with premature cessation of intravenous N-acetylcysteine therapy. Ann Pharmacother. 2008; 42: 1333-9.
Doyon, S, Klein-Schwartz, W. Hepatotoxicity despite early administration of intravenous N-acetylcysteine for acute acetaminophen overdose. Acad Emerg Med. 2009; 16: 34-9.
Whyte, IM, Buckley, et al. Acetaminophen causes an increased International Normalized Ratio by reducing functional factor VII. Ther Drug Monit. 2000; 22: 742-8.
Wallace, CI, Dargan, et al. AL. Paracetamol overdose: an evidence based flowchart to guide management. Emerg Med J. 2002; 19: 202-5.
Heard, KJ. Acetylcysteine for acetaminophen poisoning. N Engl J Med. 2008; 359(3): 285-292.
Bailey, B, Amre, et al. P. Fulminant hepatic failure secondary to acetaminophen poisoning: a systematic review and meta-analysis of prognostic criteria determining the need for liver transplantation. Crit Care Med. 2003; 31(1): 299-305.
Bernal, W, Wendon, et al. Use and outcome of liver transplantation in acetaminophen-induced acute liver failure. Hepatology. 1998; 27: 1050–1055.
Bernal, W, Donaldson, et al. J. Blood lactate as an early predictor of outcome in paracetamol-induced acute liver failure: a cohort study. Lancet. 2002; 359(9306): 558-63.
Keays, R, Harrison, et al. Intravenous acetylcysteine in paracetamol induced fulminant hepatic failure: a prospective controlled trial. BMJ. 1991; 303: 1026-9.
Dart, RC, Erdman, et al. Acetaminophen poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2006; 44: 1-18.
A 29-year old male presents to the emergency department 1h after an overdose of cocodamol. He admits to taking approximately 60 x 8/500mg tablets, with alcohol, over a 20 minute period. He has a past history of depression, treated by his GP with citalopram 20mg OD. He has no previous history of deliberate self-harm. His past medical history is otherwise unremarkable and he is not on any additional medications. He drinks approximately 40 units of alcohol per week. Physical examination is unremarkable, his pupils are normal diameter and his Glasgow Coma Scale is 15. He weighs 82kg.
Thummel KE, Slattery JT, Nelson SD. Mechanism by which ethanol diminishes the hepatotoxicity of acetaminophen. J Pharmacol Exp Ther. 1988; 245: 129-36.
Zimmerman, HJ, Maddrey, WC. Acetaminophen (paracetamol) hepatotoxicity with regular intake of alcohol: Analysis of instances of therapeutic misadventure. Hepatology. 1995; 22: 767-73.
Makin, AJ, Wendon, J, Williams, R. A 7-year experience of severe acetaminophen-induced hepatotoxicity (1987-1993). Gastroenterology. 1995; 109: 1907-16.
Smilkstein, MJ. Chronic ethanol use and acute acetaminophen overdose toxicity. J Toxicol Clin Toxicol. 1998; 36: 476.
Prescott, LF. Paracetamol, alcohol and the liver. Br J Clin Pharmacol. 2000; 49: 291-301.
Zimmerman, HJ, Maddrey, WC. Acetaminophen (paracetamol) hepatotoxicity with regular intake of alcohol: Analysis of instances of therapeutic misadventure. Hepatology. 1995; 22: 767-73.
Wood, DM, Dargan, PI, et al. AL. Measuring plasma salicylate concentrations in all patients with drug overdose or altered consciousness: is it necessary? Emerg Med J. 2005; 22: 401–403.
Prescott, LF, Illingworth, et al. Intravenous N-acetylcystine: the treatment of choice for paracetamol poisoning. Br Med J. 1979; 2: 1097-1100.
Beer, C, Pakravan, N, Hudson, M, et al. Liver unit admission following paracetamol overdose with concentrations below current UK treatment thresholds. QJM. 2007; 100(2): 93-6.
Prescott, LF. Treatment of severe acetaminophen poisoning with intravenous acetylcysteine. Arch Intern Med. 1981; 141: 386-9.
Waring, WS, Stephen, et al. Lower incidence of anaphylactoid reactions to N-acetylcysteine in patients with high acetaminophen concentrations after overdose. Clin Toxicol (Phila). 2008; 46(6): 496-500.
Bailey, B, McGuigan, MA. Management of anaphylactoid reactions to intravenous N-acetylcysteine. Ann Emerg Med. 1998; 31: 710-715.
Schwartz, EA, Hayes, BD, Sarmiento, KF. Development of Hepatic Failure Despite Use of Intravenous Acetylcysteine After a Massive Ingestion of Acetaminophen and Diphenhydramine. Ann Emerg Med. 2008;54(3): 421-3.
Smith, SW, Howland, et al. LS. Acetaminophen overdose with altered acetaminophen pharmacokinetics and hepatotoxicity associated with premature cessation of intravenous N-acetylcysteine therapy. Ann Pharmacother. 2008; 42: 1333-9.
Doyon, S, Klein-Schwartz, W. Hepatotoxicity despite early administration of intravenous N-acetylcysteine for acute acetaminophen overdose. Acad Emerg Med. 2009; 16: 34-9.
Whyte, IM, Buckley, et al. Acetaminophen causes an increased International Normalized Ratio by reducing functional factor VII. Ther Drug Monit. 2000; 22: 742-8.
Wallace, CI, Dargan, et al. AL. Paracetamol overdose: an evidence based flowchart to guide management. Emerg Med J. 2002; 19: 202-5.
Heard, KJ. Acetylcysteine for acetaminophen poisoning. N Engl J Med. 2008; 359(3): 285-292.
Bailey, B, Amre, et al. P. Fulminant hepatic failure secondary to acetaminophen poisoning: a systematic review and meta-analysis of prognostic criteria determining the need for liver transplantation. Crit Care Med. 2003; 31(1): 299-305.
Bernal, W, Wendon, et al. Use and outcome of liver transplantation in acetaminophen-induced acute liver failure. Hepatology. 1998; 27: 1050–1055.
Bernal, W, Donaldson, et al. J. Blood lactate as an early predictor of outcome in paracetamol-induced acute liver failure: a cohort study. Lancet. 2002; 359(9306): 558-63.
Keays, R, Harrison, et al. Intravenous acetylcysteine in paracetamol induced fulminant hepatic failure: a prospective controlled trial. BMJ. 1991; 303: 1026-9.
Dart, RC, Erdman, et al. Acetaminophen poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2006; 44: 1-18.
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