[Quiz] Paracetamol overdose

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An 18-year-old woman presents three days after allegedly taking 50 paracetamol tablets (25g).
Which of the following tests measured at this time point would be most helpful in determining the outcome?
(Please select 1 option)



  1. ALT concentration 
  2. Bilirubin concentration 
  3. Creatinine concentration 
  4. Paracetamol concentration  
  5. Prothrombin time  

Answer

The patient has ingested a seriously toxic dose of paracetamol.
The best determinant of this risk at 72 hours would be a prolonged prothrombin time.
Paracetamol concentrations would be rather meaningless at this time point and irrespective she should be treated with N-acetylcysteine.
There are four phases of paracetamol overdose:
* Phase 1 (0-24 hours)
o Asymptomatic
o Anorexia
o Nausea or vomiting
o Malaise
o Subclinical rise in serum aspartate transaminase (AST) - 12 hours post ingestion.
* Phase 2 (18-72 hours)
o Right upper quadrant abdominal pain, anorexia, nausea, vomiting
o Continued rise in serum transaminases levels (note this is the time slot for our patient with the alanine transaminase [ALT] rises).
* Phase 3 (72-96 hours)
o Centrilobular hepatic necrosis with continued abdominal pain
o Jaundice
o Coagulopathy
o Hepatic encephalopathy
o Nausea and vomiting
o Renal failure
o Fatality rising international normalised ratio/prothrombin time (INR/PT) from three days.
* Phase 4 (Four days to three weeks)
o Complete resolution of symptoms
o Complete resolution of organ failure.



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