This is the current release of the guideline.

Grades of recommendation (A-D, Z) and levels of evidence (1a-6) are defined at the end of the "Major Recommendations" field.

Note: These recommendations are provided in chronological order of likely clinical use. The grade of recommendation is provided in parentheses.

1. The initial history obtained by the specialist in poison information should include the patient's age and intent (Grade B), the specific formulation and dose of acetaminophen, the ingestion pattern (single or multiple), duration of ingestion (Grade B), and concomitant medications that might have been ingested (Grade D).
2. Any patient with stated or suspected self-harm or who is the recipient of a potentially malicious administration of acetaminophen should be referred to an emergency department immediately regardless of the amount ingested. This referral should be guided by local poison center procedures (Grade D).
3. Activated charcoal can be considered if local poison center policies support its prehospital use, a toxic dose of acetaminophen has been taken, and fewer than 2 hours have elapsed since the ingestion (Grade A). Gastrointestinal decontamination could be particularly important if acetylcysteine cannot be administered within 8 hours of ingestion.

Acute, Single, Unintentional Ingestion of Acetaminophen

1. Any patient with signs consistent with acetaminophen poisoning (e.g., repeated vomiting, abdominal tenderness in the right upper quadrant, or mental status changes) should be referred to an emergency department for evaluation (Grade D).
2. Patients less than 6 years of age should be referred to an emergency department if the estimated acute ingestion amount is unknown or is 200 mg/kg or more. Patients can be observed at home if the dose ingested is less than 200 mg/kg (Grade B).
3. Patients 6 years of age or older should be referred to an emergency department if they have ingested at least 10 g or 200 mg/kg (whichever is lower) or when the amount ingested is unknown (Grade D).
4. Patients referred to an emergency department should arrive in time to have a stat serum acetaminophen concentration determined at 4 hours after ingestion or as soon as possible thereafter. If the time of ingestion is unknown, the patient should be referred to an emergency department immediately (Grade D).
5. If the initial contact with the poison center occurs more than 36 hours after the ingestion and the patient is well, the patient does not require further evaluation for acetaminophen toxicity (Grade D).

Repeated Supratherapeutic Ingestion of Acetaminophen (RSTI)

1. Patients under 6 years of age should be referred to an emergency department immediately if they have ingested:
   • 200 mg/kg or more over a single 24-hour period, or
   • 150 mg/kg or more per 24-hour period for the preceding 48 hours, or
   • 100 mg/kg or more per 24-hour period for the preceding 72 hours or longer (Grade C).
2. Patients 6 years of age or older should be referred to an emergency department if they have ingested:
   • at least 10 g or 200 mg/kg (whichever is less) over a single 24-hour period, or
   • at least 6 g or 150 mg/kg (whichever is less) per 24-hour period for the preceding 48 hours or longer.

   In patients with conditions purported to increase susceptibility to acetaminophen toxicity (alcoholism, isoniazid use, prolonged fasting), the dose of acetaminophen considered as RSTI should be greater than 4 g or 100 mg/kg (whichever is less) per day (Grade D).

3. Gastrointestinal decontamination is not needed (Grade D).

Other Recommendations

1. The out-of-hospital management of extended-release acetaminophen or multi-drug combination products containing acetaminophen is the same as an ingestion of acetaminophen alone (Grade D). However, the effects of other drugs might require referral to an emergency department in accordance with the poison center's normal triage criteria.
2. The use of cimetidine as an antidote is not recommended (Grade A).

Definitions:

Grades of Recommendation and Levels of Evidence

Algorithms are provided in Appendices 4 and 5 of the original guideline document for out-of-hospital management of acute acetaminophen ingestion and out-of-hospital management of repeated supratherapeutic acetaminophen ingestion.

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.

2005

American Association of Poison Control Centers - Professional Association

Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services

Not stated

Primary Authors: Richard C. Dart, MD; PhD, Andrew R. Erdman, MD; Kent R. Olson, MD; Gwenn Christianson, MSN; Anthony S. Manoguerra, PharmD; Peter A. Chyka, PharmD; E. Martin Caravati, MD, MPH; Paul M. Wax, MD; Daniel C. Keyes, MD, MPH; Alan D. Woolf, MD, MPH; Elizabeth J. Scharman, PharmD; Lisa L. Booze, PharmD; William G. Troutman, PharmD

Panel Members: Lisa L. Booze, PharmD, Certified Specialist in Poison Information, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, Maryland; E. Martin Caravati, MD, MPH, FACMT, FACEP, Professor of Surgery (Emergency Medicine), University of Utah, Medical Director, Utah Poison Center, Salt Lake City, Utah; Gwenn Christianson, RN, MSN, Certified Specialist in Poison Information, Indiana Poison Center, Indianapolis, Indiana; Peter A. Chyka, PharmD. FAACT, DABAT, Professor, Department of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee; Richard C. Dart, MD, PhD, Director, Rocky Mountain Poison and Drug Center, Denver Health, Professor of Surgery (Emergency Medicine), University of Colorado Health Sciences Center, Denver, Colorado; Daniel C. Keyes, MD, MPH, Medical Director, Pine Bluff Chemical Demilitarization Facility, Associate Professor, Southwestern Toxicology Training Program, Dallas, Texas; Anthony S. Manoguerra, PharmD, DABAT, FAACT, Professor of Clinical Pharmacy and Associate Dean, School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, Former Director, California Poison Control System, San Diego Division, San Diego, California; Kent R. Olson, MD, FACEP, FAACT, FACMT, Medical Director, California Poison Control System, San Francisco Division, Clinical Professor of Medicine & Pharmacy, University of California, San Francisco, San Francisco, California; Elizabeth J. Scharman, PharmD, DABAT, BCPS, FAACT, Director, West Virginia Poison Center, Professor, West Virginia University School of Pharmacy, Dept. Clinical Pharmacy, Charleston, West Virginia; Paul M. Wax, MD, FACMT, Managing Director, Banner Poison Center, Professor of Clinical Emergency Medicine, University of Arizona School of Medicine, Phoenix, Arizona; Alan Woolf, MD, MPH, FACMT, Director, Program in Environmental Medicine, Children's Hospital, Boston, Associate Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts

Dr. Dart is employed by Denver Health, which provides professional services to many pharmaceutical companies, including McNeil Consumer and Specialty Pharmaceuticals.

There are no other potential conflicts of interest reported by the expert consensus panel or project staff regarding this guideline.

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on October 31, 2005. The information was verified by the guideline developer on November 28, 2005.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.