Modified release paracetamol ingestions of ≥ 10 g or ≥ 200 mg/kg (whichever is less) should receive a full course of acetylcysteine.Paracetamol levels ≥ triple the nomogram line should be discussed with a clinical toxicologist as they may require higher acetylcysteine doses.Massive paracetamol overdoses (over 30g) resulting in paracetamol concentrations more than double the nomogram line should be treated with double the dose of acetylcysteine (200 mg/kg) in the second bag of the treatment.Paracetamol ingestions between 10gm (200mg/kg) and 30gm (500mg/kg) should be treated with standard acetylcysteine infusion.Standard acetylcysteine treatment (use actual body weight):Ģ00 mg/kg (max 22 g) in 500 mL (glucose 5% or sodium chloride 0.9%) over 4 hoursįor paediatrics use a dilution volume of 7mL/kg up to a max of 500 mLġ00 mg/kg (max 11 g) in 1000 mL (glucose 5% or sodium chloride 0.9%) over 16 hoursįor paediatrics use a dilution volume of 14 mL/kg up to a max of 1000 mL Double dose acetylcysteine treatment (use actual body weight):Ģ00 mg/kg (max 22 g) in 500 mL (glucose 5% or sodium chloride 0.9%) over 4 hoursįor paediatrics use a dilution volume of 7mL/kg up to a max of 500 mLĢ00 mg/kg (max 22 g) in 1000 mL (glucose 5% or sodium chloride 0.9%) over 16 hoursįor paediatrics use a dilution volume of 14 mL/kg up to a max of 1000 mL In some circumstances, a double dose regime is required. This is just as effective as the previous three bag regime and significantly reduces adverse reactions. Standard treatment is now a two‐bag acetylcysteine IV infusion regime over 20 hours. Key changes to practice in the updated guidelines Acetylcysteine treatment It is important to check the units of measurement when using paracetamol nomograms with many laboratories recently changing from μmol/L (right axis) to mg/L (left axis).All patients with intentional self-poisoning with paracetamol should have a serum paracetamol performed, regardless of reported ingested dose.Cases that require different management include modified release paracetamol overdoses, large or massive overdoses, accidental liquid paracetamol ingestion in children and repeated supratherapeutic ingestions.The paracetamol nomogram should be used to assess the need for treatment in immediate release paracetamol ingestions with a known time of ingestion.Patients at risk of hepatotoxicity should receive intravenous (IV) acetylcysteine.
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