Preamble: why the ICU perspective is different Patients who don't die make a complete recovery.Patients with peak transaminase levels <1000 U/L usually don't develop clinically significant hepatic dysfunction. Transaminases peak 3-4 days after ingestion.Greatest risk of death during this period (with common causes being cerebral edema, septic shock, or less commonly hemorrhage).Hepatic failure emerges (encephalopathy, jaundice, coagulopathy, hypoglycemia, lactic acidosis, shock).Systemic symptoms reappear (nausea/vomiting, anorexia, malaise).Stage III (72-96 hours) = Peak liver toxicity However, massive ingestion may cause early development of transaminitis and lactic acidosis. Labs are generally normal during this period.
( 25873702) These patients should be considered for specific treatment.
Massive ingestion (>32 grams) may present with mental status alteration and lactic acidosis within 12 hours of ingestion. 🚨 Other symptoms during this period usually suggest coingestion or massive ingestion. Asymptomatic or nonspecific symptoms (anorexia, nausea/vomiting, diaphoresis). Toxicity is typically divided into stages, but this may not work perfectly in every patient (especially in patients who ingested several doses of acetaminophen over time). Inducers of CYP2E1 (increase metabolism of acetaminophen into toxic NAPQI):. Zidovudine, trimethoprim/sulfamethoxazole. Decreased hepatic capacity for glucuronidation:. ( 29605069)įactors that increase the risk of acetaminophen toxicity “Alcohol-Tylenol syndrome” – Ongoing use of several grams of acetaminophen daily along with alcohol. NyQuil and related products that combine acetaminophen with antihistamines). Patients with cold/flu symptoms who take acetaminophen along with combination cold medications (e.g. Patients with chronic pain who take acetaminophen along with combination analgesics (e.g. Peak absorption of immediate-release tablets usually occurs within 2-4 hours of ingestion. 
( 29605069, 34053705) Ingestions > 30 grams are classified as massive this may require more aggressive therapy. ( 31786822) However, this varies considerably between patients.
Acetaminophen doses above > 10 grams or >200 mg/kg (whichever is less) may be toxic.
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