START: Suspected Acetaminophen Toxicity
History of APAP ingestion or elevated level
All Pathways
Emergency MedicineEmergency
Acetaminophen Toxicity Management (JAMA 2023)
Acetaminophen Toxicity Management (JAMA 2023): START: Suspected Acetaminophen Toxicity → Obtain History → Initial Labs → Type of Ingestion? → Acute Sing...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Obtain History
Key information
- Amount ingested (mg/kg)
- Time of ingestion (critical for nomogram)
- Single vs multiple doses
- Immediate-release vs extended-release
- Co-ingestants
- Suicidal intent
03Action Initial Labs
Draw at presentation
- Serum acetaminophen level
- LFTs (AST, ALT)
- PT/INR
- BMP (Cr, glucose)
- Lactate if severe
- Repeat APAP level at 4 hours post-ingestion
04Decision Type of Ingestion?
Determines treatment approach
05Action Acute Single Ingestion
Known time, single dose
- Use Rumack-Matthew nomogram
- APAP level at 4 hours post-ingestion (or ASAP if >4h)
- Plot level on nomogram
- Above treatment line → NAC indicated
06Action GI Decontamination
If early presentation
- Activated charcoal 1g/kg (max 50g)
- Most effective within 1-2 hours of ingestion
- Consider up to 4 hours for large ingestions
- Contraindicated if altered mental status, aspiration risk
07Decision NAC Treatment Indicated?
Based on level/nomogram or clinical
- TREAT IF: Level above treatment line, Elevated transaminases with APAP detected, Unknown time but high risk, Massive ingestion (>150 mg/kg)
08Action IV NAC Protocol (21-hour)
Standard 3-bag regimen
- Loading: 150 mg/kg IV over 1 hour
- Bag 2: 50 mg/kg IV over 4 hours
- Bag 3: 100 mg/kg IV over 16 hours
- Total: 300 mg/kg over 21 hours
- Anaphylactoid reactions: slow infusion, antihistamines
09Action Monitoring During Treatment
Assess for hepatotoxicity
- LFTs q6-12 hours
- PT/INR
- Serum creatinine
- APAP level until undetectable
- Glucose (hypoglycemia in liver failure)
10Decision Continue NAC?
Criteria for stopping
- STOP NAC IF: APAP undetectable, INR <2, AST/ALT declining or normal
- CONTINUE NAC IF: INR >2, AST >1000, clinical hepatotoxicity
11Warning Acute Liver Failure
Transfer to liver transplant center
- King's College Criteria for transplant:
- - pH <7.3 after resuscitation, OR
- - PT >100 sec (INR >6.5) + Cr >3.4 + Grade III/IV encephalopathy
- Continue NAC (reduces mortality even in ALF)
- Early hepatology/transplant consult
12Outcome Recovery/Discharge
Hepatotoxicity resolved
- LFTs normalizing
- APAP undetectable
- INR normal
- Psychiatric evaluation if intentional
- Safe medication storage counseling
13Action Oral NAC (72-hour)
Alternative if IV unavailable
- Loading: 140 mg/kg PO
- Maintenance: 70 mg/kg PO q4h x 17 doses
- Mix with juice/soda for palatability
- Repeat dose if vomiting within 1 hour
- Path rejoins step 09Shared downstream outcome
- Path rejoins step 12Shared downstream outcome
14Action Repeated Supratherapeutic
RSTI - nomogram not applicable
- Total dose >4g/day (or >75 mg/kg/day)
- Treat if: APAP detectable AND AST/ALT elevated
- Or: Total dose >10g in 24h regardless of labs
- Path rejoins step 06Shared downstream outcome
Guideline Source
JAMA Network Open Consensus Statement on Acetaminophen Poisoning 2023
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Rumack-Matthew nomogram only for single acute ingestion
- Extended-release and repeated supratherapeutic ingestions need modification
- NAC dosing protocols may vary by institution
- Liver transplant criteria require specialist input
Applicable Regions
USEUGlobal
US: JAMA 2023 consensus current
Version 1Next review: 2028-01-01
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Related Resources
Frequently Asked Questions
What is the Acetaminophen Toxicity Management (JAMA 2023)?
The Acetaminophen Toxicity Management (JAMA 2023) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on JAMA Network Open Consensus Statement on Acetaminophen Poisoning 2023.
What guideline is the Acetaminophen Toxicity Management (JAMA 2023) based on?
This algorithm is based on JAMA Network Open Consensus Statement on Acetaminophen Poisoning 2023 (DOI: 10.1001/jamanetworkopen.2023.24092).
What are the limitations of the Acetaminophen Toxicity Management (JAMA 2023)?
Known limitations include: Rumack-Matthew nomogram only for single acute ingestion; Extended-release and repeated supratherapeutic ingestions need modification; NAC dosing protocols may vary by institution; Liver transplant criteria require specialist input. Individual patient factors may require deviation from these recommendations.
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