A 17 year old girl who was ‘fine’ until her boyfriend ended their relationship

A 17 year old girl who was ‘fine’ until her boyfriend ended their relationship. Out of anger, she took 10 tablets of paracetamol after drinking alcohol. She is brought into A&E by her mother. What is the SINGLE most appropriate next course of action?

A. Refer to psychiatry
B. Liver transplant
C. Refer to GP
D. Discharge home. No referral needed.
E. Start N-acetylcysteine

Referral to psychiatric team would be the most accurate option here. Acute alcohol consumption is an inhibitor of P-450 enzyme system. Since she has consumed alcohol acutely, the risk of fatal effects of paracetamol poisoning would be reduced. Not to mention that 10 tablets of paracetamol in a 17 year old is not life threatening. She does however need a psychiatric evaluation before she leaves the hospital as she was clearly trying to harm herself. Paracetamol (acetaminophen) poisoning

Initial features → Nausea, vomiting, pallor After 24 hours → Hepatic enzymes rise After 48 hours → Jaundice, an enlarged, tender liver

Hypoglycaemia, hypotension, encephalopathy, coagulopathy, coma may also occur.

When to discharge home? • If ingestion of paracetamol is < 150mg/kg in a child/adult with no hepatic risk factors

When to admit? • Admit those presenting within 8h of ingesting >150mg/kg (or an unknown amount) (For the exam, it can be quite time consuming to multiply 150mg with the weight of the patient. So we would advise you to use the number 24 as a benchmark whereby if the patient consumes more than 24 tablets (12 g) of paracetamol, then you admit him/her)

When to do a serum paracetamol concentration?
• At ≥4h post ingestion if consumed >150mg/kg (or an unknown amount)

When to give activated charcoal? • If presenting < 1h, and >150mg/kg of tablets ingested

When to give N-acetylcysteine? • If there is a staggered overdose (Note: a staggered overdose is if all the tablets were not taken within 1 hour); or • If there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or • If plasma paracetamol concentration (taken 4 hours post ingestion) is above the appropriate line • If patients presents late (>8h) and ingested dose is >150mg/kg, (or dose is unknown)