Canada, U.S. consensus guidelines for the management of acetaminophen poisoning

In Canada, approximately 4,500 hospitalizations occur each year because of acetaminophen poisoning. Acetaminophen overdose may occur as a self-harm attempt or the inadvertent consumption of repeated doses used for the treatment of pain or fever. Toxic effects of acetaminophen are characterized by hepatocellular damage, which may lead to acute liver injury, acute liver failure or death. Numerous changes in acetaminophen poisoning have occurred in recent years due to the introduction of products that contain greater amounts of acetaminophen, the availability of extended-release preparations, and new combination drugs containing acetaminophen with opioids or other ingredients. Until now, nationwide guidelines for the management of acetaminophen poisoning have been available in Canada or the United States—resulting in significant variability in patient management by poison information specialists and emergency department staff. To address this issue, clinical toxicology societies in Canada and the United States selected a panel of experts to develop consensus guidelines for the management of acetaminophen poisoning. The group of 21 experts examined guidelines from poison centres (84 guidelines) and systematically collected and reviewed the medical literature (278 publications). Guidelines were developed for emergency department management of single or repeated ingestion of acetaminophen. The panel also addressed extended-release formulations, high-risk ingestion, co-ingestion of acetaminophen and anticholinergics or opioids, age younger than six years, pregnancy, weight > 100 kg, and intravenous acetaminophen use. Acute ingestion was defined as an ingestion presenting four to 24 hours after overdose. The term “massive ingestion” was replaced with “high-risk ingestion.” Recommendations include specific criteria for emergency department triage, laboratory evaluation and monitoring parameters. The guidelines also define the role of gastrointestinal decontamination, provide detailed guidance on acetylcysteine treatment, adverse effects and stopping criteria, as well as criteria for consultation with a clinical toxicologist. Other specific treatment considerations that are addressed include acetylcysteine dosing, fomepizole administration and considerations for extracorporeal elimination and transplant evaluation. The guidelines include the following helpful algorithms: Management of acetaminophen poisoning in a medical facility Administration of acetylcysteine in the management of acetaminophen poisoning Management of repeated supratherapeutic ingestion of acetaminophen. The authors suggest that future work should focus on refining critical elements of history taking in poisoned patients, comparative effectiveness and safety research on various acetylcysteine regimens, and refining the clinical roles of fomepizole and hemodialysis in acetaminophen poisoning. Reference 1. Dart RC, Mullins ME, Matoushek T, et al. Management of acetaminophen poisoning in the US and Canada. A consensus statement. JAMA Network Open 2023;6(8):e2327739. (accessed August 10, 2023).

Canada, U.S. consensus guidelines for the management of acetaminophen poisoning

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