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The New Paracetamol Guidelines

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We have an update on the Management of Paracetamol Poisonings (MJA 203(5). 7 September 2015) (last update was in 2008) and it covers six main areas:

  1. Risk Assessment
  2. Charcoal Use
  3. Modified Release Paracetamol
  4. Large/Massive Ingestions
  5. Liquid paracetamol in children less than 6 years old.
  6. Consulting a Liver Transplant Unit

Some Notes:

  • In children less than 6 years old, use ideal weight
  • In children greater than 6 years old and in adults use actual weights to a maximum of 110kg
  • Large doses are greater than 30g paracetamol
  • Doses greater than 50g should be discussed with a toxicologist
  • These guidelines apply to oral paracetamol- advice from toxicologist needed in IV paracetamol

RISK ASSESSMENT

DOSE

CHILDREN < 6yo

CHILDREN > 6yo and ADULTS

 

Single dose over a period of <8 hours

>200mg/kg

>200mg/kg or 10g (which ever is lower)

Repeated SUPRATHERAPEUTIC ingestion

> 200mg/kg over a 24 hour period

>200mg/kg or 10g (which ever is lower) over 24 hour period

>150mg/kg per 24 hour period for preceding 48 hours

>150mg/kg or 6g (which ever is lower)

per 24 hour period for preceding 48 hours

>100mg/kg  per 24 hour period for more than 24 hours

>100mg/kg or 4g/day (which ever is lower) per 24 hour period for more than 24 hours in those with symptoms of liver injury: abdo pain, nausea and vomiting

PARACETAMOL DOSING ASSOCIATED WITH HEPATIC INJURY

CHARCOAL USE

Single Dose Immediate release

  • 50g of charcoal can be given up to 2 hours post ingestion
  • If paracetamol dose is > 30g give charcoal up to 4 hours post ingestion

Modified release Paracetamol (i.e. panadol osteo)

  • Can administer charcoal up to 4 hours post ingestion
  • If paracetamol dose taken is >30g can benefit from charcoal at > 4hours post ingestion

MODIFIED RELEASE PARACETAMOL

As in the previous guideline treatment start Acetylceistine if > 200mg/kg or 10g has been ingested, given that two assessments of paracetamol concentration must be made 4 hours apart(the first being 4 hours post ingestion)

What has changed is when to discontinue acetylcysteine infusion

  • paracetamol concentrations 4 hours apart must be below nomogram and decreasing
  • continue infusion if ALT >50U/L or paracetamol is >10mg/L(66umol/L)

LARGE/MASSIVE INGESTIONS

  • In those that ingest > 30g paracetamol, if the paracetamol level is twice the nomogram line, then double the concentration of the 16 hour infusion(no randomised control trials)
  • Continue if at near completion of the 16 hour protocol the ALT>50U/L or paracetamol levels are >10mg/L or 66umol/L

LIQUID PARACETAMOL IN CHILDREN < 6 YEARS OLD

This only applies to well children who present at less than 4 hours post ingestion

CONSULTING A LIVER TRANSPLANT UNIT

The following criteria need to be met:

  • INR >3 at 48 hours of >4.5 at any time
  • Oliguria or Creatinine > 200umol/L
  • Persistent acidosis pH<7.3 or lactate >3mmol/L
  • Systolic BP < 80mmHg despite resuscitation
  • Hypoglycaemia
  • Severe thrombocytopenia
  • Encephalopathy

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