If you work in the ED you will be familiar with patients presenting having taken excessive amounts of paracetamol. It’s such a common presentation that you really should be familiar with the management of such patients, and for as long as I can remember it’s been pretty straightforward. We looked in the BNF and followed the guidelines. Key things we needed to know were…
- Have they taken >150mg/Kg? If not, chill, you don’t need to treat.
- Was it a staggered OD? – if yes just treat them
- How long since ingestion? – check the paracetamol level &read off the BNF chart
- Are they high risk? (drugs, low weight, alcoholism etc.) – so you can choose which line to assess them on.
Now, I have to say that this was not exactly rocket science. We were not asking people to do calculus in their heads, but I must admit that I’ve been involved in several near misses over the years when patients have not had the treatment they needed because the guidelines (simple though they are) were not followed, with errors at all potential points on the protocol. My personal one when I was a junior SHO was not spotting the girl with the baggy clothes who was anorexic, a close call who did fine (but I could have done better), and my experience is not unique. according to the MHRA patients have died when presenting late to the ED.
So, what are the main changes?
- A single treatment line – so that will be the one starting at 100mg/l which is the old lower curve
- All treatments based on weight – including kids – which will simplify things
- First dose of acetylcysteine goes over one hour (used to be 15 mins)
- Don’t fret about previous hypersensitivity (I never did)
I particularly like the clear and unambiguous definition of what a staggered OD is. If the paracetamol OD was taken within an hour you can consider it a single event. I like this as it has confused people for quite some time, and to be honest it’s jolly difficult to get through 30+ tabs quickly.
So, are these changes good? Well I hope so as it is a tragedy for someone to die of a treatable condition, but I think it will increase the number of patients getting admitted to the short stay unit who have 4-hour levels between 100 and 200. In the past they would be discharged post psych review but not now. All those with 4-hour levels >100 will be in for 24 hours of treatment as an inpatient (and that will result in some complications as a result of therapy). Whilst we will have to see what effect this has in the future, bed availability is so tight at the moment that every little change could have quite dramatic effects.
What I don’t know is why levels vary around the world. As @andywebster points out, the treatment levels vary (Ed – it’s the same for adrenaline in anaphylaxis by the way). So a reduction in confusion in the UK may lead to more international confusion, unless they catch up with us of course 😉 .
@EMManchester so without any evidence we are going to treat more people? America use one line starting at 150. In oz we used one line at 200
— Andywebster (@Andywebster) September 3, 2012
(This tweet box is live and you can respond to Andy from here. Totally cool plugin courtesy of @sandnsurf)
So, overall these are sensible and reasonable changes, though it is a perhaps a bit dissapointing that one of the reasons for change is the fact that we could not get the rather simple version right before this. Having said that, simplicity is often more elegant than complexity. It’s also great to see the College of Emergency Medicine leading on this, in the past it would be something done to us, further evidence of the CEM stepping up to the plate.
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8 thoughts on “Paracetamol 2012: less means more”
Andy’s Australian experience presumably goes back a few years – our nomogram starts at 150 mg/L these days.
The UK has copied the Aussies in finally using a single treatment line on the nomogram – which is undoubtedly the way to go.
However, in A&NZ our line starts at 150mg/L (not 200 – see the 2008 MJA guidelines: https://www.mja.com.au/journal/2008/188/5/guidelines-management-paracetamol-poisoning-australia-and-new-zealand-explanation)
The level of 200 comes from the Prescott nomogram, the level of 150 from the Rumack-Matthews nomogram which already had a considerable safety factor built into to it as per FDA requirements.
I think lowering it to 100mg/L at 4 hours is over the top and will lead to needless treatment – especially of children, I suspect.
More important is getting the time of ingestion and the mg/kg dose of ingestion right in the first place, to perform an accurate risk assessment in the first place.
Thanks Chris. I guess it’s there to make things simple, but with SO many docs moving back and forth between Aus/NZ and the UK………. (actually it’s usually forth, rarely back 😉 )
I’m one of the temporary rare ones 😉 I do like that the first infusion has been slowed down to an hour – I’ve had a few wheezes and flushing on the 15min bag in the past.
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