Paracetamol overdose in children: management following an initial N-acetylcysteine regimen

To cite: Rajaraman N, Gray L, Anderson M, et al. Arch Dis Child Educ Pract Ed Epub ahead of print: [please include Day Month Year]. doi:10.1136/archdischild2022324906 © Author(s) (or their employer(s)) 2022. No commercial reuse. See rights and permissions. Published by BMJ. BACKGROUND A 14yearold girl presents to the emergency department 6 hours following an intentional acute paracetamol overdose (POD). She confesses to having recent suicidal ideation following a fallout with her boyfriend. Blood tests reveal a paracetamol concentration of 235 mg/L, with normal pH and lactate on blood gas, normal transaminases, urea, creatinine and coagulation profile. The attending clinician, following a risk assessment, admits her and informs the Child and Adolescent Mental Health Services (CAMHS) and the safeguarding team. The paracetamol concentration is above the treatment threshold on the paracetamol nomogram and she is managed as per the TOXBASE protocol with Nacetylcysteine (NAC) infusion. Before the end of the last bag of NAC infusion, repeat blood tests show an international normalised ratio (INR) 1.9, alanine aminotransferase (ALT) 324 IU/L, pH 7.35 and lactate 2.3 mmol/L (reference range, table 1). What do we do next? POD is a common presentation and if not treated promptly, can lead to irreversible liver failure which may necessitate liver transplant or be fatal in some cases. The initial management is as per the National Poisons Information Service (NPIS) recommendations within TOXBASE. If blood tests following treatment are within reference ranges, the management is straightforward. However, difficulty arises when faced with persistent transaminitis, clotting derangement, acute kidney injury (AKI) or lactic acidosis following the initial regimen. This article focuses on the management of POD following the completion of the initial NAC regimen (irrespective of the standard threebag or the twobag Scottish and Newcastle Acetylcysteine ProtocolSNAP) recommended on TOXBASE. This article does not replace TOXBASE and liver specialist advice and is for general guidance.