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tox.acetaminophen-overdose.core.v1

Acetaminophen (paracetamol) overdose

toxicologyacuteadultpediatricpregnancyacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is fully authored (21/21 quality-bar). Atoms split files not present — content lives in monolithic manifest. No _design-brief.md authored for the paracetamol-overdose-in-adults package. evidence.pmids refreshed 2026-05-22: removed non-APAP POINT/REDUCE placeholders and inserted ACMT NAC-duration / APAP-overdose clinical review anchors. Calculator gaps: Rumack-Matthew nomogram, King's College criteria, NEWS2 are referenced in the manifest but not yet present as `calc.*` entries in clinical-tools-registry.ts; treat as registry blockers for INTEGRATED. Regimen RxCUIs live-checked against RxNav 2026-05-22: acetylcysteine 197, activated charcoal 272, lactulose 6218. No engine-specific test_files declared; pathway-builder coverage exists but not earmarked for this engine. Deepened 2026-04-27: added Prescott IV 21-h regimen ladder (load → bag2 → bag3) + PO 72-h alternative, ED + ICU setting playbooks, action plan (post-OD safety + suicide prevention), 7 severity triggers (Rumack-Matthew, KCC pH/triple/lactate, late/staggered, massive, pregnancy), sibling diff vs salicylate-OD and cirrhosis.

Entry points (4)

  • symptom
    Reported ingestion of acetaminophen / paracetamol
    acetaminophen_ingestion_history
  • lab_abnormality
    Detectable serum acetaminophen level
    apap_level_detectable
  • lab_abnormality
    Unexplained ALT elevation in poly-substance/intentional ingestion
    alt_elevated_unexplained
  • symptom
    Intentional overdose / suicide attempt
    intentional_overdose

Required inputs (19)

  • agerequired
    demographic • used at CONTEXT
    Pediatric and adult NAC weight bands; pediatric dilution rules (<20 kg)
  • weight_kgrequired
    demographic • used at CONTEXT
    NAC dosing is mg/kg with 110 kg cap
  • time_since_ingestion_hoursrequired
    history • used at CONTEXT
    Nomogram applicability (4–24 h); empiric NAC if >8 h or unknown
  • total_dose_ingested_grequired
    history • used at CONTEXT
    Massive ingestion (>30 g) flag; staggered vs single decision
  • staggered_or_unknown_timerequired
    history • used at CONTEXT
    Nomogram does not apply when staggered or time unclear
  • serum_apap_4h_or_laterrequired
    lab • used at INITIAL_WORKUP
    Plotted on Rumack-Matthew nomogram for treatment-line decision
  • altrequired
    lab • used at INITIAL_WORKUP
    ALT >1000 = hepatotoxicity; trends drive NAC continuation
  • inrrequired
    lab • used at INITIAL_WORKUP
    INR rising after 24 h → ongoing injury; KCC component
  • creatininerequired
    lab • used at INITIAL_WORKUP
    KCC criterion (Cr >300) and AKI co-morbidity
  • arterial_phrequired
    lab • used at INITIAL_WORKUP
    KCC arterial pH <7.3 single criterion → transplant referral
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Lactate >3.5 mmol/L early predictor of poor outcome
  • glucoserequired
    lab • used at INITIAL_WORKUP
    Hypoglycemia common in hepatotoxicity; D10 infusion trigger
  • salicylate_levelrequired
    lab • used at INITIAL_WORKUP
    Mandatory co-ingestion screen
  • ethanol_level
    lab • used at INITIAL_WORKUP
    Glutathione depletion + sedation modifier
  • chronic_alcohol_use
    history • used at CONTEXT
    CYP2E1 induction + GSH depletion lowers toxic threshold
  • enzyme_inducer_meds
    history • used at CONTEXT
    INH/rifampin/phenytoin/carbamazepine increase NAPQI
  • pregnancy_status
    history • used at CONTEXT
    NAC is safe in pregnancy; MFM/fetal monitoring required
  • prior_nac_reaction
    history • used at CONTEXT
    Anaphylactoid reaction history changes infusion approach
  • west_haven_grade
    symptom • used at RISK_STRATIFICATION
    Grade III/IV encephalopathy is a KCC criterion + intubation trigger

12-phase flow (12)

  1. 1FRAME
    Confirm acute APAP toxicity scope; route massive/late presenters to transplant pathway
    inputs: time_since_ingestion_hours, total_dose_ingested_g
    advance: Acute APAP overdose confirmed; massive/late triggers flagged
  2. 2ENTRY
    Document ingestion history, intent, formulation (XR/combo), co-ingestants
    inputs: age, weight_kg, staggered_or_unknown_time
    advance: Demographics + ingestion narrative captured
  3. 3CONTEXT
    Capture inducer meds, alcohol, malnutrition, pregnancy, prior NAC reaction, psych history
    inputs: chronic_alcohol_use, enzyme_inducer_meds, pregnancy_status, prior_nac_reaction
    advance: Risk modifiers documented
  4. 4RED_FLAGS
    Screen for massive dose, level >300 mg/L at 4 h, ALT >1000, INR >2, pH <7.3, lactate >3.5, encephalopathy, hypoglycemia, rising Cr, KCC met
    inputs: arterial_ph, lactate, glucose, inr
    actions: protocol.septic_shock
    advance: Red flags acted on (KCC referral made if any criterion met)
  5. 5INITIAL_WORKUP
    4-h (or later) APAP, LFTs, INR, BMP, glucose, lactate, ABG, salicylate, ethanol, UDS, ECG, hCG
    inputs: serum_apap_4h_or_later, alt, inr, creatinine, arterial_ph, lactate, glucose, salicylate_level
    actions: apap_overdose, panel.abg, panel.cardiac, panel.renal
    advance: Baseline labs returned and plotted on Rumack-Matthew
  6. 6BRANCHING_WORKUP
    If staggered/unknown time → empiric NAC; if late presenter with hepatotoxicity → ALF workup; if massive → ICU + dialysis evaluation
    inputs: staggered_or_unknown_time, alt
    advance: Phenotype branch selected (single/staggered/massive/late/pregnancy/peds)
  7. 7DIFFERENTIAL
    Rule out viral hepatitis, ischemic hepatitis, alcoholic hepatitis, mushroom (Amanita), Wilson, autoimmune, AFLP/HELLP if pregnant, salicylate co-ingestion
    advance: APAP confirmed as primary contributor or co-contributor
  8. 8RISK_STRATIFICATION
    Apply Rumack-Matthew (4–24 h known time) or empiric criteria; assess KCC; compute MELD 3.0; West Haven grade
    inputs: serum_apap_4h_or_later, inr, creatinine, arterial_ph, west_haven_grade
    actions: calc.meld3, calc.ckd_epi_2021
    advance: Treatment-line status, KCC status, and MELD documented
  9. 9TREATMENT
    Activated charcoal if <1–2 h; IV NAC 21-h protocol (or SNAP 12-h); empiric NAC if >8 h or staggered; D10 if hypoglycemic; vitamin K if INR high; lactulose for HE; intubate if grade III/IV
    inputs: weight_kg, time_since_ingestion_hours
    advance: NAC initiated and dosing documented; supportive care active
  10. 10DISPOSITION
    ICU if encephalopathy/acidosis/massive; transfer to transplant centre if any KCC criterion or evolving organ dysfunction; psych admission if intentional
    advance: Disposition assigned (ICU/floor/transplant centre/psych)
  11. 11MONITORING
    Serial LFTs q12h, INR q6–12h, Cr q12h, glucose q4–6h, lactate/pH q4–6h, West Haven q4h, repeat APAP at end of NAC, NAC reaction watch first hour
    inputs: alt, inr, glucose, lactate
    actions: panel.cardiac, panel.renal, panel.abg
    advance: Monitoring cadence active; NAC continued until ALT trending and INR <2
  12. 12FOLLOWUP
    Psychiatry safety plan, hepatology if injury, PCP med review, social work, poison-prevention education, child protection if pediatric
    advance: Discharge plan + safety plan documented