1. Clinical Policy: Critical Issues in the Management of Patients Presenting to the Emergency Department With Acetaminophen Overdose the American College of Emergency Physicians Clinical Policies Subcommittee [Ann Emerg Med. 2007;50:292-313]

2. Introduction NAC(N-acetylcycteine) Sulfhydryl group donor Sulfhydryl group donor Conjugate NAPQI into nontoxic Metabolite Conjugate NAPQI into nontoxic Metabolite Blunt the hepatotoxicity of NAPQI Blunt the hepatotoxicity of NAPQI Hepatotoxicity definition Any increase in AST Any increase in AST Severe hepatotoxicity : AST > 1000 IU/L Severe hepatotoxicity : AST > 1000 IU/L Hepatic failure : hepatotoxicity + HEP Hepatic failure : hepatotoxicity + HEP

3. Rumack-Mattew nomogram Single ingestion Known point in time 4 hr to 24 hr

4. Methodology Recommendation Level A : High degree of clinical certainity Level A : High degree of clinical certainity Level B : Moderate degree of C.C. Level B : Moderate degree of C.C. Level C : Preliminary, inconclusive,… Level C : Preliminary, inconclusive,…

5. Critical Question What are the indications for NAC ? In the acetaminophen overdose patient In the acetaminophen overdose patient With a known time of acute ingestion With a known time of acute ingestion Who can be risk stratified by the Rumack- Methew nomogram Who can be risk stratified by the Rumack- Methew nomogram

6. Recommendation Level A None specified None specified Level B Possible or probable risk within 8 – 10 hr Possible or probable risk within 8 – 10 hr Do not give NAC for no risk pt Do not give NAC for no risk pt Level C None specified None specified

7. Clinical questions What are the indications for NAC? In the acetaminophen overdose patient In the acetaminophen overdose patient Who cannot be risk stratified by the R.M nomogram Who cannot be risk stratified by the R.M nomogram

8. Recommendation Level A None specified None specified Level B Administer NAC to patient Administer NAC to patient With hepatic failure thought to be due to Acetaminophen With hepatic failure thought to be due to Acetaminophen Level C Administer NAC to patient Administer NAC to patient Repeated supratherapeutic ingestions Repeated supratherapeutic ingestions

9. Acetaminophen Poisoning an Evidence-Based Consensus Guideline for Out-of-Hospital management Acetaminophen Poisoning an Evidence-Based Consensus Guideline for Out-of-Hospital management American Association of Poison Centers

10. ED visit required Suicidal attempt regardless of amounts Suicidal attempt regardless of amounts Acute, single, unintentional ingestion Acute, single, unintentional ingestion Any patient with sign Any patient with sign Age 200 mg/kg Age 200 mg/kg Age ≥ 6 yrs, dose unknown, >10 g or 200 mg/kg Age ≥ 6 yrs, dose unknown, >10 g or 200 mg/kg

11. RSTI RSTI Age < 6 yrs Age < 6 yrs Dose > 200 mg/kg in 24 hrs Dose > 200 mg/kg in 24 hrs Dose > 150 mg/kg per 24 hrs in 48 hrs Dose > 150 mg/kg per 24 hrs in 48 hrs Dose > 100 mg/kg per 24 hrs in 72 hrs Dose > 100 mg/kg per 24 hrs in 72 hrs Age ≥ 6 yrs Age ≥ 6 yrs Dose > 10 g or 200 mg/kg in 24 hrs Dose > 10 g or 200 mg/kg in 24 hrs Dose > 6 g or 150 mg/kg per 24 hrs in 48 hrs Dose > 6 g or 150 mg/kg per 24 hrs in 48 hrs Susceptibility↑ in alcoholism, INH, NPO.. Susceptibility↑ in alcoholism, INH, NPO.. Dose > 4 g or 100 mg/kg per day Dose > 4 g or 100 mg/kg per day ED visit required

12. Observation at Home After 36 hrs of ingestion, No symptoms After 36 hrs of ingestion, No symptoms

13. Are one or two dangerous? Methyl salicylate exposure in toddlers The journal of Emergency Medicine 32;2007:63-69

14. Methyl salicylate

15. 1 mL wintergreen(98% methyl salicylate) Equivalent to 1400 mg salicylate Equivalent to 1400 mg salicylate Methyl salicylate

16. Salicylate Poisoning an Evidence-Based Consensus Guideline for Out-of-Hospital management Salicylate Poisoning an Evidence-Based Consensus Guideline for Out-of-Hospital management American Association of Poison Centers

17. Self-harm, regardless of amounts Self-harm, regardless of amounts Presence of typical symptom Presence of typical symptom Hematemesis, tachypnea, hyperpnea, dyspnea, tinnitus, deafness, lethargy, seizure, unexplined lethargy, confusion Hematemesis, tachypnea, hyperpnea, dyspnea, tinnitus, deafness, lethargy, seizure, unexplined lethargy, confusion Acute ingestion > 150 mg/kg or 6.5 g AE Acute ingestion > 150 mg/kg or 6.5 g AE ED visit required

18. Oil of wintergreen Oil of wintergreen Lick or taste, Age < 6 yrs Lick or taste, Age < 6 yrs Dose 4 ml, Age > 6 yrs Dose 4 ml, Age > 6 yrs ED visit required

19. Asymptomatic dermal exposure to methyl salicylate or salicylic acid Asymptomatic dermal exposure to methyl salicylate or salicylic acid Eye sxposure, irrigation 15 min, more Eye sxposure, irrigation 15 min, more Symptom F/U Symptom F/U 12 hrs in non enteric coated 12 hrs in non enteric coated 24 hrs in enteric coated 24 hrs in enteric coated Observation at Home

20. Woman of last trimester of pregnancy Woman of last trimester of pregnancy Below the toxic dose Below the toxic dose No ED referral symptom No ED referral symptom → Primary physician, OBGY… → Primary physician, OBGY… Special consideration