Emergency Medicine

Tox i c o l o g y 171

SPECIFIC POISONS

2 Review the blood results:

(i) Plot the serum paracetamol level on the paracetamol nomogram

for all patients presenting between 4 and 24 h after an acute,

single ingestion of paracetamol (Fig. 5.1).

(a) the treatment nomogram has been simplified from

previously, with a single treatment line now for all patients

following paracetamol ingestion

(b) this line has been lowered by 25% from prior standard lines.

(ii) Treat all patients who have a serum paracetamol level above the

nomogram treatment line (Fig. 5.1).

(iii) A raised PTI (INR) or alanine aminotransferase (ALT) levels

>1000 IU/L define significant hepatotoxicity.

3 NAC, the antidote for paracetamol, is highly effective when commenced

within 8 h of poisoning. Administer NAC in the following circumstances:

(i) Patients presenting within 8 h of ingestion, with a 4–8-h serum

paracetamol level above the nomogram treatment line (see Fig.

5.1).

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Blood paracetamol concentration (

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Blood paracetamol concentration (mg/L)

Time (hours)

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Figure 5.1 Treatment nomogram for paracetamol poisoning. Treat any patient
with a serum paracetamol level above the nomogram treatment line. (Make certain
the correct units are used). Reproduced with permission from Daly FFS, Fountain JS,
Murray L et al. (2008) Guidelines for the management of paracetamol poisoning
in Australia and New Zealand – explanation and elaboration. Medical Journal of
Australia 188 : 296–301.