This is the current release of the guideline.

Definitions for the strength of evidence (Class I-III) and strength of recommendations (Level A-C) are repeated at the end of the Major Recommendations.

1. What are the indications for N-acetylcysteine (NAC) in the acetaminophen overdose patient with a known time of acute ingestion who can be risk stratified by the Rumack-Matthew nomogram?

   Level A recommendations. None specified.

   Level B recommendations.

   1. Administer NAC to acute acetaminophen overdose patients with either possible or probable risk for hepatotoxicity as determined by the Rumack-Matthew nomogram to reduce the incidence of severe hepatotoxicity and mortality, ideally within 8 to 10 hours postingestion.
   2. Do not administer NAC to acute acetaminophen overdose patients with no risk for hepatotoxicity as determined by the Rumack-Matthew nomogram.

   Level C recommendations. None specified.

2. What are the indications for NAC in the acetaminophen overdose patient who cannot be risk stratified by the Rumack-Matthew nomogram?

   Level A recommendations. None specified.

   Level B recommendations. Administer NAC to patients with hepatic failure thought to be due to acetaminophen.

   Level C recommendations. Administer NAC to patients who have hepatotoxicity thought to be due to acetaminophen and have a suspected or known acetaminophen overdose, including repeated supratherapeutic ingestions.

Definitions:

Literature Classification Schema^

^Some designs (e.g., surveys) will not fit this schema and should be assessed individually.

*Objective is to measure therapeutic efficacy comparing >2 interventions.

**Objective is to determine the sensitivity and specificity of diagnostic tests.

***Objective is to predict outcome including mortality and morbidity.

Approach to Downgrading Strength of Evidence

*See "Description of Methods Used to Analyze the Evidence" field for more information.

Strength of Recommendations

Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues)

Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies)

Level C recommendations. Other strategies for patient management that are based on preliminary, inconclusive, or conflicting evidence, or, in the absence of any published literature, based on panel consensus

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2007 Jun

American College of Emergency Physicians - Medical Specialty Society

American College of Emergency Physicians

American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Management of Patients Presenting to the Emergency Department With Acetaminophen Overdose

American College of Emergency Physicians Clinical Policies Committee (Oversight Committee)

Subcommittee (Writing Committee) on Critical Issues in the Management of Patients Presenting to the Emergency Department With Acetaminophen Overdose: Stephen J. Wolf, MD (Chair); Kennon Heard, MD; Edward P. Sloan, MD, MPH; Andy S. Jagoda, MD

American College of Emergency Physicians Clinical Policies Committee (Oversight Committee): Andy S. Jagoda, MD (Chair 2003-2006, Co-Chair 2006-2007); Wyatt W. Decker, MD (Co-Chair 2006-2007); Deborah B. Diercks, MD; Jonathan A. Edlow, MD; Francis M. Fesmire, MD; Steven A. Godwin, MD; Sigrid A. Hahn, MD; John M. Howell, MD; J. Stephen Huff, MD; Thomas W. Lukens, MD, PhD; Donna L. Mason, RN, MS, CEN (ENA Representative 2004-2006); Michael Moon, RN, CNS, MSN, CEN (ENA Representative 2004); Anthony M. Napoli, MD (EMRA Representative 2004-2006); Devorah Nazarian, MD; Jim Richmann, RN, BS, MA(c), CEN (ENA Representative 2006-2007); Scott M. Silvers, MD; Edward P. Sloan, MD, MPH; Molly E. W. Thiessen, MD (EMRA Representative 2006-2007); Robert L. Wears, MD, MS (Methodologist); Stephen J. Wolf, MD; Cherri D. Hobgood, MD (Board Liaison 2004-2006); David C. Seaberg, MD, CPE (Board Liaison 2006-2007); Rhonda R. Whitson, RHIA, Staff Liaison, Clinical Policies Committee and Subcommittees

Relevant industry relationships for the following Acetaminophen Overdose Subcommittee members are as follows: Dr. Heard is the Medical Toxicology Fellowship Director at the Rocky Mountain Poison and Drug Center, which has research and business contracts with McNeil Consumer Products and Cumberland Pharmaceuticals. Dr. Heard has received honoraria from Cumberland Pharmaceuticals and from McNeil Consumer Products to provide educational lectures and materials for projects other than this clinical policy.

Relevant industry relationships are those relationships with companies associated with products or services that significantly impact the specific aspect of disease addressed in the critical question.

Emergency Nurses Association - Medical Specialty Society

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on January 21, 2008. The information was verified by the guideline developer on February 15, 2008.