Poisoning and Overdose 237220.An 18-year-old woman is brought to the ED by her mother. The patient
is diaphoretic and vomiting. Her mom states that she thinks her daughter
tried to commit suicide. The patient admits to ingesting a few handfuls of
extra-strength Tylenol approximately 3 hours ago. Her temperature is 99.1°F,
BP is 105/70 mm Hg, HR is 92 beats per minute, RR is 17 breaths per minute,
and oxygen saturation is 99% on room air. On examination, her head and
neck are unremarkable. Cardiovascular and pulmonary examinations are
within normal limits. She is mildly tender in her right upper quadrant but
there is no rebound or guarding. Bowel sounds are normoactive. She is alert
and oriented and has no focal deficits on neurologic examination. You admin-
ister 50 g of activated charcoal. At this point, she appears well and has no
complaints. Her 4-hour serum acetaminophen (APAP) concentration returns
at 350 μg/mL. You plot the level on the nomogram seen below. Which of the
following is the most appropriate next step in management?
1,000500100
5010
51
4 8 12 16 20 24
Time after ingestion, hoursPlasma level of acetaminophenProbable
hepatotoxicityNo hepatic
injury anticipateda. Discharge home with instructions to return if symptoms return
b. Observe for 6 hours and if the patient still has no complaints discharge her home
c. Admit to the hospital for serial abdominal examinations
d. Admit to the psychiatry unit and keep on suicide watch while performing
serialabdominal examinations
e. Begin NAC and admit to the hospital
(Reproduced, with permission, from Brunton LL et al.Goodman and Gilman’s The Pharma-
cological Basis Therapeutics. New York, NY: McGraw-Hill, 2006: 694.)