QuestionSBA
QuestionChoice
There is no current indication for referral, however this may be necessary in the future. Criteria for referral are either a pH of <7.3 (note that the VBG has been reported to be normal), or all three of: INR >6.5, creatinine >300 umol/L, grade III/IV encephalopathy.
10028294
d
Refer to liver transplant centre
QuestionChoice
This is correct. The patient has suffered from a (likely unintentional) staggered paracetamol overdose, which means that N-acetylcysteine should be started straight away.
10028291
a
Commence N-acetylcysteine
QuestionChoice
This is inappropriate. The history and blood results are suggestive of an staggered overdose which should be treated promptly. Waiting for the paracetamol level is not necessary in a staggered overdose.
10028293
c
Await paracetamol levels
QuestionChoice
This is not the single best course of action to take. Activated charcoal may be administered in a single (not staggered) overdose, within an hour of ingestion.
10028292
b
Administer activated charcoal
QuestionChoice
This is inappropriate. The history and blood results are suggestive of a staggered paracetamol overdose which should be treated promptly.
10028295
e
Observe for 12 hours
QuestionComment
You would also commence this in patients presenting after 24 hours with signs of acute liver injury and a raised ALT 
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Edema Dominant
QuestionComment
How do I tell that it is staggered
50555
QuestionComment
They were taking regular doses of paracetamol, which you assume means taken as directed. The issue is the extra cold and flu tablets she was taking which likely include paracetamol. Meaning it would be staggered throughout the courses of these painkillers. Hope that makes sense :))
51708
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Supraventricular Lion
QuestionComment
Staggered means it was taken over a period longer than 1 hour
53722
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Carl Sinoma
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Fungal Metabolism
Concept
Chapter
2693
4620
Paracetamol Overdose
Topic
161
Emergency Medicine
18056
N-acetylcysteine should be started in paracetamol overdose if serum levels are above the treatment line on the nomogram, the timing of ingestion is uncertain, signs of liver damage are present or expected, or a significant amount of paracetamol has been ingested (e.g., >150 mg/kg in adults or >200 mg/kg in children).
A 18-year-old female has been suffering with a cold and is feeling increasingly unwell. She is admitted to hospital after blood tests performed by her GP were abnormal:


||||
|---------------------------|:-------:|--------------------|
|Alanine Aminotransferase (ALT)|2044 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|1023 IU/L|10 - 40|
|Bilirubin|54 µmol/L|< 17|
|Creatinine|100 µmol/L|60 - 120|
|International Normalised Ratio (INR)|2.6|1.0|


A venous blood gas taken in the emergency department is normal.


On further questioning, she reports taking regular doses of paracetamol, along with regular over the counter cold and flu tablets over the past week.


What is the single best course of action to take?
a